Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands

Evaluation of the dissemination and implementation of pressure ulcer guidelines in Dutch nursing homes

RATIONALE, AIMS AND OBJECTIVES

Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes.

METHODS

Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons.

RESULTS

The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication.

CONCLUSIONS

The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines.

Organizational culture, team climate, and quality management in an important patient safety issue: nosocomial pressure ulcers

BACKGROUND

Increasingly, policy reform in health care is discussed in terms of changing organizational culture, creating practice teams, and organizational quality management. Yet, the evidence for these suggested determinants of high-quality care is inconsistent.

AIMS

To determine if the type of organizational culture (Competing Values Framework), team climate (Team Climate Inventory), and preventive pressure ulcer quality management at ward level were related to the prevalence of pressure ulcers. Also, we wanted to determine if the type of organizational culture, team climate, or the institutional quality management related to preventive quality management at the ward level.

METHODS

In this cross-sectional observational study multivariate (logistic) regression analyses were performed, adjusting for potential confounders and institution-level clustering. Data from 1274 patients and 460 health care professionals in 37 general hospital wards and 67 nursing home wards in the Netherlands were analyzed. The main outcome measures were nosocomial pressure ulcers in patients at risk for pressure ulcers (Braden score ≤ 18) and preventive quality management at ward level.

RESULTS

No associations were found between organizational culture, team climate, or preventive quality management at the ward level and the prevalence of nosocomial pressure ulcers. Institutional quality management was positively correlated with preventive quality management at ward level (adj. β 0.32; p < 0.001).

CONCLUSIONS AND IMPLICATIONS

Although the prevalence of nosocomial pressure ulcers varied considerably across wards, it did not relate to organizational culture, team climate, or preventive quality management at the ward level. These results would therefore not subscribe the widely suggested importance of these factors in improving health care. However, different designs and research methods (that go beyond the cross-sectional design) may be more informative in studying relations between such complex factors and outcomes in a more meaningful way.

Protective effect of caspase inhibition on compression-induced muscle damage

There are currently no effective therapies for treating pressure-induced deep tissue injury. This study tested the efficacy of pharmacological inhibition of caspase in preventing muscle damage following sustained moderate compression. Adult Sprague-Dawley rats were subjected to prolonged moderate compression. Static pressure of 100 mm Hg compression was applied to an area of 1.5 cm2 in the tibialis region of the right limb of the rats for 6 h each day for two consecutive days. The left uncompressed limb served as intra-animal control. Rats were randomized to receive either vehicle (DMSO) as control treatment (n =8) or 6 mg kg⁻¹ of caspase inhibitor (z-VAD-fmk; n =8) prior to the 6 h compression on the two consecutive days.Muscle tissues directly underneath the compression region of the compressed limb and the same region of control limb were harvested after the compression procedure.Histological examination and biochemical/molecular measurement of apoptosis and autophagy were performed. Caspase inhibition was effective in alleviating the compression-induced pathohistology of muscle. The increases in caspase-3 protease activity, TUNEL index, apoptotic DNA fragmentation and pro-apoptotic factors (Bax, p53 and EndoG) and the decreases in anti-apoptotic factors (XIAP and HSP70) observed in compressed muscle of DMSO-treated animals were not found in animals treated with caspase inhibitor. The mRNA content of autophagic factors (Beclin-1, Atg5 and Atg12) and the protein content of LC3, FoxO3 and phospho-FoxO3 that were down-regulated in compressed muscle of DMSO-treated animals were all maintained at their basal level in the caspase inhibitor treated animals. Our data provide evidence that caspase inhibition attenuates compression-induced muscle apoptosis and maintains the basal autophagy level. These findings demonstrate that pharmacological inhibition of caspase/apoptosis is effective in alleviating muscle damage as induced by prolonged compression.

Pressure ulcer incidence in Dutch and German nursing homes: design of a prospective multicenter cohort study

BACKGROUND

Pressure ulcers are a common and serious health care problem in all health care settings. Results from annual national pressure ulcer prevalence surveys in the Netherlands and Germany reveal large differences in prevalence rates between both countries over the past ten years, especially in nursing homes. When examining differences in prevalence and incidence rates, it is important to take into account all factors associated with the development of pressure ulcers. Numerous studies have identified patient related factors, as well as nursing related interventions as risk factors for the development of pressure ulcers. Next to these more process oriented factors, also structural factors such as staffing levels and staff quality play a role in the development of pressure ulcers. This study has been designed to investigate the incidence of pressure ulcers in nursing homes in the Netherlands and Germany and to identify patient related factors, nursing related factors and structural factors associated with pressure ulcer development. The present article describes the protocol for this study.

METHODS/DESIGN

A prospective multicenter study is designed in which a cohort of newly admitted nursing home residents in 10 Dutch and 11 German nursing homes will be followed for a period of 12 weeks. Data will be collected by research assistants using questionnaires on four different levels: resident, staff, ward, and nursing home.

DISCUSSION

The results of the study will provide information on the incidence of pressure ulcers in Dutch and German nursing homes. Furthermore, information will be gathered on the influence of patient related factors, nursing related factors and structural factors on the incidence of pressure ulcers. The present article describes the study design and addresses the study's strengths and weaknesses.

Bibliometric analysis of pressure ulcer research: 1990-2009

PURPOSE

Bibliometric evaluation provides a method for evaluating trends in publications related to a specific topic. This search focused on pressure ulcer (PU) care; journals and authors with the greatest contribution and impact were emphasized.

DESIGN

Bibliometric evaluation.

METHODS

Data encompassing the period from 1990 to 2009 were extracted from the Science Citation Index online version. We analyzed selected documents with "pressure ulcer" as a part of the title, abstract, or key words and reported the following parameters: trends of publication output, document types, subject category, journal pattern, authorship, and research in nursing disciplines.

RESULTS

The annual number of articles on PUs grew at a rapid rate, from approximately 39 in 1991 to 259 in 2009. The main subject categories in which research on PUs was conducted were surgery and nursing, each of which accounted for more than 10% of total articles. The United States was the dominant country in terms of volume of articles. The relationship between nurse staffing and PU-related outcomes is currently the major focus of PU nursing research, followed by risk assessment scale evaluations.

CONCLUSION

We found that the number of PU-related publications has grown at a rapid rate over the past 20 years, reflecting an increasing awareness of the importance of PU prevention and management.

Studying factors related to pressure ulcers prevention: a marginal scale model for modelling heterogeneity among hospitals

RATIONALE, AIMS AND OBJECTIVES

The purpose of this study was to analyse risk factors associated with the presence of pressure ulcer development in patients referred to several Italian hospitals, taking properly into account the within-hospital outcome correlation.

METHODS

We analysed data from a prevalence survey coordinated by the European Pressure Ulcer Advisory Panel on 12,000 hospitalized patients in Italy, collecting information on patient's risk, presence of ulcers and prevention measures. The article describes the bases which generalized estimating equations rely on as well as their statistical properties. The article compares different model specifications in the light of background knowledge of the survey data and model assumptions, and discusses the potential for this modelling approach to apply in similar statistical situations.

RESULTS

In accordance with existing literature, factors associated with pressure ulcers in hospitalized patients were identified as Braden scale, age and assistance-connected aspects. Between-hospital variability seemed to be explained by the adopted degree of prevention (use of preventive equipment combined with a repositioning strategy).

CONCLUSIONS

Modelling the covariance matrix or the scale argument of the correlated binary responses (presence/absence of pressure ulcers) by using moment estimators based on generalized estimating equations prevents optimistic inference and provides an important insight into the role of structural differences among hospitals.

Pressure ulcers in Jordan: a point prevalence study

BACKGROUND

Pressure ulcers are a common problem among hospitalised patients. Several prevalence studies have been conducted internationally but there is a paucity of research on pressure ulcer in the Arab world in general and in Jordan specifically.

PURPOSE

The aim of this study was to quantify the prevalence rate of pressure ulcers in Jordan, and to compare these figures with other studies conducted using the same methods.

DESIGN

A cross-sectional survey design.

PARTICIPANTS

All inpatients older than eighteen in both university and general hospitals in Jordan. Patients in the emergency, day care and maternity wards were excluded.

INSTRUMENTS

European Pressure Ulcer Advisory Panel (EUPAP) data collection form.

METHODS

The survey was conducted by examining patients' skin. Pressure ulcers were classified according to the EPUAP grading system. Risk of pressure ulcer development was assessed using the Braden scale. Data were collected on preventive measures recorded in the clinical setting.

RESULTS

The overall prevalence rate was 12% (All percentages are rounded to the nearest digit) (7% when Grade I excluded). The sacrum and heel were the most common affected sites. Grade one was the most common grade (44%). Only 17% of the patients at risk received adequate prevention.

CONCLUSION

The pressure ulcer prevalence rate in Jordan is lower than that published in most studies utilising the same methodology. Despite this relatively low prevalence very few patients at risk received adequate prevention, and there is therefore a need to raise the awareness for pressure ulcer prevention in Jordan. Furthermore, differences in age and frailty in the Jordanian sample could explain the low prevalence.

The prevalence of pressure ulcers in four paediatric institutions

AIM AND OBJECTIVE

Pressure ulcers are a common nursing care issue in hospitals. They are associated with psychological and physical suffering, an increased morbidity and mortality rate and higher overall health care costs. The aim of the current study is to describe the frequency of pressure ulcers in a paediatric care setting and to identify the population at risk, as well as to assess the factors predisposing to the development of pressure ulcers.

DESIGN

A point prevalence study.

METHODS

The study was conducted in four paediatric hospitals in the German-speaking part of Switzerland and included children from the age of 0-18 years. The method of data collection was a direct systematic inspection and assessment of the skin, taking into account the clinical condition of the patient for risk assessment. A valid risk assessment and data collection instrument was used and, each patient was assessed by a previously instructed rater pair.

RESULTS

Of all possible patients, 81% (n = 155) were included. An overall pressure ulcer prevalence of 27.7% (including grade 1) was registered. Thirty-six patients (84%) had grade 1 ulcers, including many caused by external medical devices. Sixty-five per cent (n = 100) of all patients were considered at risk (Braden score < or = 20) of developing a pressure ulcer. Thirty-five per cent of patients in the risk group were afflicted with one or more pressure ulcers.

CONCLUSIONS

The prevalence of pressure ulcers in paediatric patients is greater then previously appreciated and the problem requires further exploration. The high percentage of grade 1 pressure ulcers caused by medical devices requires nursing interventions to prevent lesions for these patients.

RELEVANCE TO CLINICAL PRACTICE

The high prevalence rate in paediatric patients is disconcerting and requires further exploration in terms of interventions needed to improve outcomes for this patient group.

Factors of importance to the development of pressure ulcers in the care trajectory: perceptions of hospital and community care nurses

AIM

The study aimed at describing contributing factors for the progression or regression of pressure ulcers in the care trajectory as they were understood by nurses working in hospitals or community care.

BACKGROUND

The development of pressure ulcers is considered to be connected with early prevention and awareness among nurses and some studies have indicated that the care trajectory may be a weak point.

DESIGN

The study was carried out with a qualitative design.

METHOD

Fifteen nurses from two Swedish hospitals and 15 nurses from community care were interviewed during 2005. Qualitative content analysis was used to make an understanding of patterns possible.

FINDINGS

Three main categories arose, showing that pressure ulcers were considered to be affected in the care trajectory by factors related to the individual patient, to the healthcare personnel and to the healthcare structure. Hospital and community care nurses mostly had corresponding perceptions of these factors.

CONCLUSION

The study both confirmed previous findings and added new knowledge about factors that may affect pressure ulcer in the trajectory of care. The informants' views of nurses' responsibilities and their attitudes towards the care of pressure ulcers could, along with their views on the organisation of care, increase the understanding of the occurrence of pressure ulcers. The need for development and clarification of the organisation and responsibility of pressure ulcer care in the care trajectory was stressed. Relevance to clinical practice. The study highlighted attitudes and values among registered nurses, as well as to how to preserve their commitment and increase their knowledge concerning prevention of pressure ulcers.

Assessment of incidence, cause, and consequences of pressure ulcers to evaluate quality of provided care

BACKGROUND

Pressure ulcers are one of the most frequently registered complications in general surgery.

OBJECTIVE

To obtain insight into the incidence, cause, and consequences of pressure ulcers and to evaluate the value of pressure ulcer registration to assess quality of care.

RESULTS

During the 9-year study period, 275 pressure ulcers were registered (5.8% of total registered complications). Age and female sex were independent risk factors for pressure ulcer development. Pressure ulcer classification was as follows: mild (53.3%), moderate (35.6%), severe (9.5%), and irreversible damage (1.5%). Patients undergoing hip surgery and major limb amputation were at risk for pressure ulcer development (10.4% and 8.8%, respectively). In most patients (89.5%), pressure ulcers had no consequences other than local wound therapy; in 12 patients (4.4%), pressure ulceration led to alteration in medication; in 15 patients (5.5%), length of hospital stay was prolonged; and four patients (0.4%) suffered from irreversible damage.

CONCLUSION

The incidence of pressure ulcers is strongly correlated to sex, age, and indication of admittance. Most ulcers were classified as mild and had no consequences. The insight obtained into incidence, cause, and consequences of pressure ulcers can be used as an indicator of quality of provided care if adjusted for case mix and indication of operation.

An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting

BACKGROUND

Measurement error can seriously affect the validity of pressure ulcer risk assessment and of pressure ulcer classification.

OBJECTIVES

Determination of interrater reliability and agreement of pressure ulcer risk and pressure ulcers using the Braden scale and the EPUAP system.

DESIGN AND SETTING

Duplicate assessments by trained nurses during two nationwide pressure ulcer prevalence surveys in the years 2007 and 2008 in The Netherlands in the home care setting.

PARTICIPANTS

Home care clients which participated in 2007 (n=352) and 2008 (n=339) in the pressure ulcer prevalence surveys.

METHODS

The Braden scale was used to assess pressure ulcer risk. Skin examination was conducted to detect pressure related tissue damages and to classify them according to the EPUAP.

RESULTS

In 2007 and 2008, Intraclass Correlation Coefficients for Braden scale sum scores were 0.90 (95% CI: 0.88-0.92) and 0.88 (95% CI: 0.85-0.91) respectively, and corresponding Standard Errors of Measurement were 1.00 and 0.98. 95% limits of agreement were -2.8 to 2.8 and -2.7 to 2.7 respectively. The items "moisture", "sensory perception" and "nutrition" contained largest amounts of measurement error. Proportions of agreement for the classification of pressure ulcers were 96% and interrater reliability was 0.81 and 0.79. Most disagreements were observed for the classification of grade 1 pressure ulcers.

CONCLUSIONS

The standardized study procedure applied in the annual nationwide pressure ulcer prevalence surveys leads to reliable and reproducible results regarding pressure ulcer risk and pressure ulcer prevalence in the home care setting. Researchers and practitioners should be careful when drawing inferences from single pressure ulcer risk factors included in the Braden scale. Descriptions of the items "moisture", "sensory perception" and "nutrition" should be made more clearly and unambiguous.

Using hospital administrative data to evaluate the knowledge-to-action gap in pressure ulcer preventive care

RATIONALE, AIMS AND OBJECTIVES

Issues of overuse, underuse and misuse are paramount and lead to avoidable morbidity and mortality. Although evidence-based practice is advocated, the widespread implementation of this kind of practice remains a challenge. This is also the case for evidence-based practice related to the prevention of pressure ulcers, which varies widely in process and outcome in Belgian hospital care. One major obstacle to bridging this knowledge-to-action gap is data availability. We propose using large-scale hospital administrative data combined with the latest evidence-based methods as part of the solution to this problem.

METHOD

To test our proposal, we applied this approach to pressure ulcer prevention, using an administrative dataset with regard to 6030 patients in 22 Belgian hospitals as a sample of nationally available data. Methods include a systematic review approach, evidence grading, recommendations formulation, algorithm construction, programming of the rule set and application on the database.

RESULTS

We found that Belgian hospitals frequently failed to provide appropriate prevention care. Significant levels of underuse, up to 28.4% in pressure ulcer prevention education and 17.5% in the use of dynamic systems mattresses, were detected. Figures for overuse were mostly not significant. Misuse couldn't be assessed.

CONCLUSIONS

These results demonstrate that this approach can indeed be successfully used to bridge the knowledge-to-action gap in medical practice, by implementing an innovative method to assess underuse and overuse in hospital care. The integrative use of administrative data and clinical applications should be replicated in other patient groups, other datasets and other countries.

Hospital pressure ulcer prevalence rates and number of raters

AIM

The purpose of this study was to evaluate the influence of different numbers of nurse raters conducting skin inspection (one or two) on observed pressure ulcer prevalence rates.

BACKGROUND

Pressure ulcer prevalence and incidence rates are important outcome measures for the quality of care. To ensure reliability and comparability of such rates standardisation of study methods is recommended. It is assumed that data accuracy can be improved if skin inspection is conducted by a team of two raters.

DESIGN

A secondary data analysis of pressure ulcer prevalence data was conducted.

METHOD

Groups of hospital patients which were examined by one (n = 2420) or two raters (n = 15,009) were compared regarding demographic characteristics, pressure ulcer risk and pressure ulcer prevalence. Logistic regressions were conducted to examine the association between the number of raters (one or two) and the outcome pressure ulcer (yes/no).

RESULTS

Groups of one and two raters were comparable regarding demographic characteristics. There was no statistically significant difference regarding pressure ulcer prevalence between both groups (p = 0.222). There was no relation between the number of raters and the probability of identifying a pressure ulcer patient (p = 0.060).

CONCLUSIONS

Pressure ulcer prevalence rates in the analysed studies were not affected by the number of raters. There seems to be no relation between the numbers of nurses conducting skin inspection and observed prevalence rates.

RELEVANCE TO CLINICAL PRACTICE

Conducting pressure ulcer prevalence studies require a lot of effort and personal costs. Provided that one nurse alone or a team of two nurses rate the existence of pressure ulcers equally it is no longer obligatory to have two raters. This would save resources. However, when patients are restricted in their mobility two nurses are recommended to provide assistance in patient turning.

Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers

AIMS

To determine incidence of pressure ulcers in patients at risk according to the Waterlow scale in intensive care units and to evaluate the effects of risk factors in critically ill patients.

BACKGROUND

Pressure ulcers continue to be an important health problem that increases the risk of illness and death, extends patients' length of hospital stay and increases healthcare expenses.

DESIGN

The study was conducted as a descriptive and prospective study.

METHOD

The sample consisted of 140 patients. Data were collected using a data collection form, the skin assessment instrument and the Waterlow scale.

RESULTS

The incidence of pressure ulcers in intensive care unit patients was found to be 14.3%. The majority of pressure ulcers (74%) were grade I. The mean length of time for pressure ulcer development was found to be 10.4 (SD 1.85) days. A statistically significant difference was found in the patients for pressure ulcer development according to their level of consciousness, activity, cooperation, length of stay, Waterlow scale score and C-reactive protein level. In the multiple stepwise logistic regression analysis, the most influential factors for pressure ulcer development were determined to be length of stay and activity level.

CONCLUSIONS

Extra care needs to be taken to prevent pressure ulcer development in intensive care unit patients who have an extended length of stay, are dependent for activities, have high Waterlow scores, are unconscious and are not cooperative.

RELEVANCE TO CLINICAL PRACTICE

This study determined the incidence of and factors that can affect the development of pressure ulcers in intensive care unit patients who are in a high risk group for the development of pressure ulcers and presented the importance of having Turkish nurses implement interventions directed at these factors.

Risk factors and prevention among patients with hospital-acquired and pre-existing pressure ulcers in an acute care hospital

AIMS AND OBJECTIVES

This study aimed to describe and identify risk factors associated with hospital-acquired pressure ulcers among adults in an acute care hospital compared with patients with pre-existing pressure ulcers present on admission. A further aim was to identify the preventive measures performed with both groups respectively.

BACKGROUND

Pressure ulcers occur most often in older and immobile persons with severe acute illness and neurological deficits. However, few studies have addressed risk factors that are associated with hospital-acquired pressure ulcers compared with patients with pre-existing pressure ulcers.

DESIGN

A point prevalence study with a cross-sectional survey design was conducted at a Swedish university hospital.

METHOD

Data on 535 patients were recorded using a modified version of the protocol developed and tested by the European Pressure Ulcer Advisory Panel, including the Braden scale for risk assessment.

RESULTS

The prevalence of pressure ulcers was 27% (95% confidence interval, 23-31%). Higher age and a total Braden score below 17 were significantly associated with the presence of pressure ulcers. Among individual risk factors higher age, limited activity level and friction and shear while seated or lying down were associated with hospital-acquired pressure ulcers, whereas only higher age and friction and shear were associated with the presence of pressure ulcers in the overall sample. There was an overall sparse use of preventive measures to relieve pressure.

CONCLUSION

The findings of the present study revealed that pressure ulcers and the insufficient use of preventive measure to relieve pressure is still a problem in acute care settings. A continued focus must be placed on staff training in identifying patients at risk for pressure ulcers development.

RELEVANCE TO CLINICAL PRACTICE

Increasing the ability to identify patients who are at risk for pressure ulcer development can assist in preventing unnecessary complications and suffering as well as reduce costs.

Prevalence of pressure ulcers in three university teaching hospitals in Ireland

AIM

Pressure ulceration is a significant, but preventable, cause of morbidity and resource utilisation in hospital populations. Data on pressure ulcer prevalence in Ireland are limited. This study aims to determine (i) the point-prevalence of pressure ulcers in three teaching hospitals in Ireland and (ii) risk factors for their development.

METHODS

Eight teams of one doctor and one nurse visited 672 adult patients over a 2-day period in three teaching hospitals. Each patient was examined and pressure ulcers graded with the European Pressure Ulcer Advisory Panel system. Mental test score, Barthel index, type of support surface, length of stay, documentation of risk assessment and serum albumin were recorded.

RESULTS

Point-prevalence of pressure ulceration was 18.5%. Seventy-seven percent of pressure ulcers were hospital-acquired, 49% grade 1, 37% grade 2, 11% grade 3 and 3% grade 4. Reduced mobility, urinary incontinence, cognitive impairment, low serum albumin and length of stay were significantly associated with pressure ulcers. Multivariate logistic regression analysis found reduced mobility (odds ratio 8.84; 95% CI 5.04-15.48, p<0.0001) and length of stay (odds ratio 1.02; 95% CI 1.01-1.02, p<0.0001) to be predictive of the presence of pressure ulcers. Age, gender and risk assessment documentation were not associated with pressure ulcers. Sixty-five percent of patients with pressure ulcers were positioned on appropriate support surfaces.

DISCUSSION

Point-prevalence of pressure ulceration was 18.5%, similar to international data. Regular audit of prevalence, prevention and management strategies may raise awareness, influence resource allocation and ultimately improve patient care.

Malnutrition as a risk factor for the development of pressure ulcers

Malnutrition - as a fundamental aspect both in genesis as in healing of pressure ulcers - is the object of this update paper. Countless studies point out that malnutrition, immune function alterations, hypoalbuminemia, low hemoglobin levels, as well as low diet intake, as responsible for an increase in the risk of developing these lesions. Therefore, it is essential to include the assessment of the nutrition status - monitoring of the calorie-protein intake and the difficulties to use the nutrients - in the prevention and treatment protocols of this type of chronic wound.

The effectiveness of massage with and without dimethyl sulfoxide in preventing pressure ulcers: A randomized, double-blind cross-over trial in patients prone to pressure ulcers

BACKGROUND

Although guidelines advise against massage, it is one of the methods widely regarded and used by nurses to prevent pressure ulcers (PU).

OBJECTIVES

The purpose of this study was to examine the effectiveness of different variations of massage in preventing pressure ulcers.

METHODS

A randomized, double-blind cross-over design, in which patients of nursing homes who are prone to PU underwent two of the three possible interventions; 'position changes only', 'massaging with an indifferent cream' and 'massaging with a dimethyl sulfoxide (DMSO) cream'.

RESULTS

The results of three interventions did not differ significantly. DMSO did not fulfil the expectations raised by literature and a previous pilot-study.

Cytokine and chemokine release upon prolonged mechanical loading of the epidermis

At this moment, pressure ulcer risk assessment is dominated by subjective measures and does not predict pressure ulcer development satisfactorily. Objective measures are, therefore, needed for an early detection of these ulcers. The current in vitro study evaluates cytokines and chemokines [interleukin 1alpha (IL-1alpha), interleukin 1 receptor antagonist (IL-1RA), tumor necrosis factor alpha (TNF-alpha) and interleukin 8 (CXCL8/IL-8)] as early markers for mechanically-induced epidermal damage. Various degrees of epidermal damage were induced by subjecting commercially available epidermal equivalents (EpiDerm) to increasing pressures (0, 50, 75, 100, 150, and 200 mmHg) for 24 h, using a loading device. At the end of the loading experiment, tissue damage was assessed by histological examination and by evaluation of the cell membrane integrity. Cytokines and chemokines were determined in the culture supernatant. Sustained epidermal loading resulted in an increased release of IL-1alpha, IL-1RA, TNF-alpha and CXCL8/IL-8. This was first observed at 75 mmHg, when the tissue was only slightly damaged. Swollen cells, vacuoles, necrosis and affected cell membranes were observed at pressures higher than 75 mmHg. Furthermore, at 150 and 200 mmHg, the cells in the lower part of the epidermis were severely compressed. In conclusion, IL-1alpha, IL-1RA, TNF-alpha and CXCL8/IL-8 are released in vitro as a result of sustained mechanical loading of the epidermis. The first increase in cytokines and chemokines was observed when the epidermal tissue was only slightly damaged. Therefore, these cytokines and chemokines are potential markers for the objective, early detection of mechanically-induced skin damage, such as pressure ulcers.

Microstructural analysis of deformation-induced hypoxic damage in skeletal muscle

Deep pressure ulcers are caused by sustained mechanical loading and involve skeletal muscle tissue injury. The exact underlying mechanisms are unclear, and the prevalence is high. Our hypothesis is that the aetiology is dominated by cellular deformation (Bouten et al. in Ann Biomed Eng 29:153–63, 2001; Breuls et al. in Ann Biomed Eng 31:1357–364, 2003; Stekelenburg et al. in J App Physiol 100(6):1946–954, 2006) and deformation-induced ischaemia. The experimental observation that mechanical compression induced a pattern of interspersed healthy and dead cells in skeletal muscle (Stekelenburg et al. in J App Physiol 100(6):1946–954, 2006) strongly suggests to take into account the muscle microstructure in studying damage development. The present paper describes a computational model for deformation-induced hypoxic damage in skeletal muscle tissue. Dead cells stop consuming oxygen and are assumed to decrease in stiffness due to loss of structure. The questions addressed are if these two consequences of cell death influence the development of cell injury in the remaining cells. The results show that weakening of dead cells indeed affects the damage accumulation in other cells. Further, the fact that cells stop consuming oxygen after they have died, delays cell death of other cells.

EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators

OBJECTIVE

The aim of this study was to determine the effects of quality improvement programs for pressure ulcer prevention by conducting a follow-up survey in a hospital in Sweden.

DESIGN

A cross-sectional survey design with comparison between data collected in 2002 and 2004.

SETTING AND SUBJECTS

All inpatient areas were surveyed in the surgical, medical, and geriatric departments in a university hospital. A total of 369 patients were included.

INSTRUMENTS

The European Pressure Ulcer Advisory Panel data collection form including some additional questions.

METHODS

The 1-day survey was conducted on March 23, 2004. Each patient was visited by 2 registered nurses, who inspected the patient's skin for any pressure ulcer classified according to the EPUAP grading system.

RESULTS

There were no significant differences in gender, age, or Braden score between the patients in surgical, medical, or geriatric care in 2002 and 2004. The overall prevalence of pressure ulcers was 33.3% (grade 1 excluded: 10.9%) in 2002 and 28.2% (grade 1 excluded: 14.1%) in 2004. In surgical care, the prevalence was reduced from 26.8% to 17.3% (P = .051). In medical care, the prevalence was 23.6% in 2002 and 26.7% in 2004. Corresponding prevalence figures for geriatric care were 59.3% and 50.0%. A quarter of the patients in surgical care, a third in medical care, and more than half in geriatric care had a pressure ulcer upon arrival at the ward. The use of pressure-reducing mattresses had increased significantly from 16.0% to 42.7% in medical care (P = .000).

CONCLUSIONS

The EPUAP methodology has facilitated the introduction of pressure ulcer as a quality indicator at hospital level. Pressure ulcer prevalence surveys with a standardized methodology should be repeated on a regular basis in order to stimulate quality improvement.

The Norton, Waterlow, Braden, and Care Dependency ScalesL Comparing Their Validity When Identifying Patients' Pressure Sore Risk

OBJECTIVES

We compared the sensitivity and specificity of the Norton, Waterlow, and Braden Scales in identifying patients at pressure sore risk. An additional goal was to determine whether or not the Care Dependency Scale (CDS) is able to detect patients at risk for pressure sore development.

METHODS

The investigation was part of a prevalence study involving 754 patients in 3 Berlin hospitals. A questionnaire was used containing the subscales of the 3 risk calculators (Norton, Waterlow, and Braden), and the CDS. On the specified day nurses filled in the questionnaire using data obtained from the patients' charts and direct visualization of the patients' skin.

RESULTS

Thirty-four out of 754 patients had at least 1 pressure ulcer. Comparing the 3 risk assessment tools, the Waterlow scale demonstrated the highest sensitivity (0.86) and the Norton scale demonstrated the highest specificity (0.75). Individuals with pressure sores were more likely to be care dependent (t-test: P< .01); 27 of them had a CDS score lower than 55. Using the score of 55 as the cut-off point, the CDS demonstrated a sensitivity of 0.74 and a specificity of 0.83.

SUMMARY

This study demonstrated remarkable differences among the 3 commonly used risk assessment tools, in regards to sensitivity and specificity. Moreover, the CDS seems to have a diagnostic value similar to the 3 commonly used risk assessment calculators.

Appraising and comparing pressure ulcer guidelines

BACKGROUND

Whilst considerable activity has been related to guideline development for nurses regarding pressure ulcer prevention and management, no attempt has been made to comparatively evaluate these guidelines against some form of quality indicators.

AIM

To compare and contrast four national pressure ulcer guidelines, and identify similarities and differences in their quality and content.

METHODS

An international comparative appraisal method, using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, was undertaken to appraise four published pressure ulcer guidelines. Two further domains were added to the AGREE instrument to assess comparability of the guidelines and their perceived contribution to practice. An international group undertook the comparative appraisal.

RESULTS

The domain scores for each guideline show some but not total agreement among reviewers. One particular set of guidelines was identified as scoring highest in a majority of AGREE domains. Overall, evidence of variability exists between pressure ulcer guidelines and common areas of development to consider for all guidelines.

IMPLICATIONS FOR PRACTICE

The results raise many questions concerning the "best" pressure ulcer guideline to use, particularly related to the AGREE scoring. Some notable shortcomings exist in all the pressure ulcer guidelines reviewed and these shortcomings need to be addressed from a quality perspective. However, other issues such as style of reporting and potential contribution to practice might more fully affect choice by practitioners as opposed to guideline developers.

CONCLUSIONS

Notable differences exist among the four guidelines that are possibly explained by different approaches to development and also because of different cultural factors and intentions for use. Whilst the AGREE tool identifies the quality of the guideline development process it still requires local engagement with practitioners to determine which guideline should be implemented.

Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients

OBJECTIVE

To describe the short-term and long-term effects of a hospital-wide pressure ulcer prevention and treatment guideline on both the incidence and the time to the onset of pressure ulcers in critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Adult intensive care department of a university medical center.

PATIENTS

Critically ill patients (n = 399).

INTERVENTIONS

A guideline for pressure ulcer care was implemented on all intensive care units. The attention of nurses for timely transfer to a specific pressure-reducing device was an important part of this guideline.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, demographics, pressure ulcer risk profile at admission, daily pressure ulcer grading, and type of mattress were determined to describe the short-term and long-term effects 3 and 12 months after the implementation. The incidence density of pressure ulcers grade II-IV decreased from 54 per 1000 patient days at baseline to 32 per 1000 days (p = .001) 12 months after the implementation. The median pressure ulcer-free time increased from 12 days to 19 days (hazard rate ratio, 0.58; p = .02). After adjustment for differences in risk factors in a Cox proportional hazard model, the number of preventive transfers to special mattresses was the strongest indicator for the decreased risk of pressure ulcers (hazard rate ratio, 0.22; p < .001). The number needed to treat to prevent one pressure ulcer during the first 9 days was six.

CONCLUSIONS

The implementation of a guideline for pressure ulcer care resulted in a significant and sustained decrease in the development of grade II-IV pressure ulcers in critically ill patients. Timely transfer to a specific mattress (i.e., transfer before the occurrence of a pressure ulcer) was the main indicator for a decrease in pressure ulcer development.

Pressure ulcer care in Spain: nurses? knowledge and clinical practice

AIM

This paper is a report of a study to determine: (a) Spanish nurses' level of knowledge of existing guidelines for pressure ulcer prevention and treatment, (b) the level of implementation of this knowledge in clinical practice and (c) the professional and educational factors that influence knowledge and practice.

BACKGROUND

Improvement in pressure ulcer care depends both on the dissemination of knowledge and on its implementation in clinical practice. Studies carried out in several countries have demonstrated gaps in knowledge about recommendations for pressure ulcer care and deficiencies in their implementation.

METHODS

A survey was carried out between September 2001 and June 2002, targeting a cluster randomized sample of 2006 Registered Nurses and Licensed Practice Nurses working at hospitals, primary healthcare centres and elder care centres in Andalusia (Spain).

RESULTS

The response rate was 36.9% (n = 740). The level of knowledge of prevention interventions was 79.1%, while that of treatment interventions was 75.9%. The levels of implementation in clinical practice were notably lower: 68.1% for prevention, and 65.3% for treatment. Nurses holding a university degree obtained higher scores, and those who had received specific education in pressure ulcer care obtained higher scores both for knowledge and clinical practice. Taking part in research projects also improved knowledge implementation.

CONCLUSION

Although most of the recommendations on pressure ulcer care found in guidelines are well known by nurses, there is a group of interventions about which they have insufficient knowledge and low implementation rates.

Pressure ulcer prevalence in Europe: a pilot study

RATIONALE AND AIMS

Numerous prevalence studies have been conducted. The problem with these studies is that prevalence proportions cannot be compared with each other, because of differences in performance of each survey. There is no agreed standardized method for determining prevalence proportions. This study aimed to develop and pilot a uniform data collection instrument and methodology to measure the pressure ulcer prevalence and to get some insight into pressure ulcer prevalence across different patient groups in Europe.

METHODS

Pressure ulcer experts from different European countries developed a data collection instrument, which included five categories of data: general data, patient data, risk assessment, skin observation and prevention. A convenience sample of university and general hospitals of Belgium, Italy, Portugal, UK and Sweden participated in the study. In each participating hospital, teams of two trained nurses who collected the data on the wards were established. All patients admitted before midnight on the day of the survey and older than 18 years were included.

RESULTS

The data collection instrument and study procedure of the survey were found to be effective by all participants. 5947 patients were surveyed in 25 hospitals in five European countries. The pressure ulcer prevalence (grade 1-4) was 18.1% and if grade 1 ulcers were excluded, it was 10.5%. The sacrum and heels were the most affected locations. Only 9.7% of the patients in need of prevention received fully adequate preventive care.

CONCLUSION

The methodology is sufficiently robust to measure and compare pressure ulcer prevalence in different countries. The pressure ulcer prevalence was higher than expected and relatively few patients received adequate prevention. This indicates that more attention to prevention is needed in Europe.

Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses

BACKGROUND

Pressure ulcers are a common, painful and costly condition. Results of a 1991 study into the knowledge among Dutch hospital nurses on the usefulness of measures to prevent pressure ulcers showed moderate knowledge. Results were confirmed by subsequent studies. In recent years, Dutch guidelines have been updated and the attention given to pressure ulcer care has been increased. This was expected to improve pressure ulcer care and to increase nurses' knowledge. The aims of the current study were to investigate (1) how much nurses employed in Dutch hospitals know about the usefulness of 28 preventive measures considered in the most recent national pressure ulcer guideline; (2) whether differences in knowledge exist between nurses working in hospitals that audit pressure ulcers and those employed in hospitals that do not; and (3) to study whether knowledge among Dutch hospital nurses regarding the usefulness of preventive measures had changed between 1991 and 2003.

METHODS

A cross-sectional study design among nurses employed in Dutch hospitals in 2003 was used to investigate their knowledge and differences in knowledge between nurses employed in different types of institution. A comparative design was used to assess whether knowledge differed between this population and that of Dutch hospital nurses in 1991. The nurses' knowledge was assessed by a written questionnaire. Data of 522 respondents meeting the inclusion criteria were analyzed and compared with the results of the 351 nurses included in the 1991 study.

RESULTS

Knowledge in 2003 was slightly better than that in 1991. The nurses were moderately aware of the usefulness of preventive measures. Nurses employed in organizations that monitored pressure ulcers did not display greater knowledge than those employed in organizations that did not do so.

CONCLUSION

Knowledge among Dutch hospital nurses about the usefulness of measures to prevent pressure ulcers seems to be moderate. Being employed in an institution that monitors pressure ulcer care hardly affects the knowledge level. Knowledge about prevention has improved little since 1991.

Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial

AIMS AND OBJECTIVES

To evaluate whether postponing preventive measures until non-blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2-4) when compared with the standard risk assessment method.

BACKGROUND

To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non-blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach.

DESIGN

Randomized-controlled trial.

METHODS

Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non-blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non-blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene-urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days.

RESULTS

In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2-4) was not significantly different between the experimental (6.8%) and control group (6.7%).

CONCLUSION

Significantly fewer patients need preventive measures when prevention is postponed until non-blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method.

RELEVANCE TO CLINICAL PRACTICE

Using the appearance of non-blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.

L’escarre à l’hôpital en 2003 : enquête de prévalence un jour donné

BACKGROUND

To determine the prevalence of pressure sores in a university hospital and to assess the risk of developing a pressure sore.

METHODS

A one-day survey was performed in all hospitalized patients, day hospital excepted. The Garches scale was used to assess the severity of pressure sores and the Braden scale was used to measure the patient's risk for the development of pressure ulcers.

RESULTS

One thousand six hundred and eleven patients were included, mean age was 62+/-23 years and 53.3% were over 65 years old. In hospitalized patients, 64% were in acute care, 29% in intermediate medicine and long-term care and 7% in intensive care units. We have found 675 pressure sores in 268 patients, mean age of 76 years; 263 decubitus ulcers were acquired during hospitalization. The most frequent sites were heels (46%) and sacrum (26%). Stage 1 pressure ulcers showed 33% of the total. The total prevalence was 16.6%, 95% CI (14.9-18.6), the hospital acquired pressure sores prevalence was 7.5%, all stages included. A Braden score less than or equal to 15 was found in 29.1% of hospitalized patients. Standard mattresses were used in 37% of patients with pressure sores. Multivariate analysis showed that age and a Braden score less than or equal to 15 were significantly associated with pressure sores.

CONCLUSION

Pressure sores are still an important problem in hospital; occurrence must be considered as an iatrogenic event and management requires a multidisciplinary approach.

Intervention studies for prevention of pressure ulcers in Turkey: a literature review

AIM

To examine critically the literature published in the Turkish language (1955-2004) related to risk assessment tool(s), their application to nursing care and prevention of pressure ulcers (PrUs). Specific objectives were to identify the advantages of risk assessment and prevention of PrUs in hospital; to establish the most valid and reliable methods available to evaluate the effectiveness of PrU prevention programmes; to determine methodological problems encountered by researchers and explore how these were overcome; and to present the findings so they could be used to develop a valid and reliable audit tool based upon the empirical evidence.

METHODS

All journals and convention booklets published in Turkey related to nursing between the years 1955-2004 were examined. Because many journals in Turkey are not yet available by electronic means, the published Turkish articles were all examined by hand. A total of 3031 articles in 17 nursing journals and 36 congress books (convention booklets) were examined. Five articles were found to meet the study criteria and were taken into the study and evaluated.

CONCLUSION

There is a need to determine valid and reliable assessment methods, and the results need to be recorded on standard forms. In addition, it is important to increase the motivation of nursing personnel who give direct patient care to use the tools available in order to prevent the development of PrUs. From the review findings it is apparent that in Turkey, there is a dearth of research evidence upon which to base practice in the sphere of PrU prevention, and further research is urgently required.

The reliability of two observation methods of nonblanchable erythema, Grade 1 pressure ulcer

Accurate identification of nonblanchable erythema (NBE) is essential in pressure ulcer prevention. This descriptive study assessed interrater reliability between a researcher and trained nurses in observing blanchable erythema and NBE and examined the predictive validity and level of agreement between two observation methods for NBE. Findings suggest that the transparent disk method should be preferred to the finger method. The interrater reliability between the researcher and the nurses was substantial and was higher for the observations at the sacrum than for those at the heels. Educational level and years of nursing experience did not seem to influence interrater reliability.

Massage to prevent pressure ulcers: knowledge, beliefs and practice. A cross-sectional study among nurses in the Netherlands in 1991 and 2003

BACKGROUND

Pressure ulcers are a major problem in all areas of health care in the Netherlands. National guidelines for the prevention and treatment of pressure ulcers were originally developed in 1985 and revised in 1991 and 2002. The value of these guidelines can be questioned because it seems they are not in line with the beliefs and practice of the caregivers and only 5% of them are evidence-based.

AIMS AND OBJECTIVES

To get a better insight into nurses' current knowledge, beliefs and performed practices relating to massage, a study was designed to assess changes in these three aspects after the publication of the 2002 Dutch national guidelines. The outcome was compared with the situation in 1991, the year in which the previous guidelines were published.

DESIGN AND METHOD

A cross-sectional comparative study was designed using written questionnaires. Questions were formulated regarding knowledge and beliefs about prevention methods and the actual use of these methods in the prevention of pressure ulcers. The 2003-survey population consisted of nurses working in the Netherlands and was approached at random via subscriptions to Nursing News (i.e. Verpleegkunde Nieuws), a Dutch professional journal or via affiliations to an institution participating in the 2003 National Prevalence Survey of Pressure Ulcers.

RESULTS AND CONCLUSIONS

Compared with the 1991 findings, the 2003 results show an improvement for the topic of pressure ulcers, but a deterioration regarding dehydration. It is obvious that the knowledge of the current CBO-guidelines on massage is still not widely distributed as it should be. Our overall conclusion is that the differences in responses between 1991 and 2003 are significant and suggest that the nurses were better informed in 2003.

RELEVANCE TO CLINICAL PRACTICE

For the improvement of health care in the domain of pressure ulcer preventions, we need more than an accurate implementation of new or existing guidelines. Guidelines should also be based on qualitative, methodological well-designed studies to be evidence-based.

Can near infrared spectroscopy measure the effect of pressure on oxygenation of sacral soft tissue?

OBJECTIVE

To test whether near infrared spectroscopy (NIRS) is applicable for the examination of the influence of external pressure on oxygenation of the soft tissues in the sacral area.

METHOD

Tissue oxygenation was measured in 33 healthy volunteers in the prone position. A NIRS probe was positioned over the sacrum and external pressure was applied in 10 mmHg increments, from 20 mmHg to 200 mmHg and then decreased. At each level, tissue oxygen saturation (StO2) was measured. To test reproducibility, the protocol was repeated in six volunteers, in whom the thickness of the soft-tissue envelope at different levels of external pressure was assessed using ultrasound.

RESULTS

There was wide variability in StO2 courses between the 33 subjects, with a non-linear relationship between pressure and StO2. The only consistent finding was that the StO2 was significantly higher after decreasing pressure than at the initial pressure of 20 mmHg, which is indicative of reactive hyperaemia. Despite the application of high external pressures, reasonable tissue oxygenation was maintained in 19 of 33 subjects. Reproducibility of the measurements was poor. Comparison of soft-tissue thickness with corresponding StO2 values showed that, with increasing pressure, the percentage decrease in tissue thickness was higher than the decrease in tissue oxygenation.

CONCLUSION

This study confirms that NIRS is not useful for assessing tissue oxygenation in pressure ulcer research due to unacceptable inter-individual variability and poor reproducibility of measurements.

Escarres dans un hôpital universitaire de court séjour

OBJECTIVES

To determine the prevalence of pressure sores, their risk factors, and the responsible microbial agents in an acute-care hospital and to evaluate their management.

METHOD

A prevalence survey was conducted from 5 July through 9 July 2004. Investigators completed a standardized questionnaire for each hospitalized patient, including demographic data (age, sex, previous hospitalizations, etc.) and Braden scale risk factors (sensory perception, humidity, activity, mobility, nutrition, and friction and shear). Two experts in skin care detected pressure sores by physical examination of the patients. Each pressure sore was swabbed and inoculated on selective media. Management was evaluated by reviewing the clinical charts of each patient with a pressure sore.

RESULTS

The study included 535 adult patients (aged 59 +/- 19 years): 75 ulcer sores were observed in 37 patients (prevalence=6.9%). Stage I sores accounted for 24% of the total, stage II for 29%, stage III 31%, and stage IV 16%. The most frequent site was the heel (41%), followed by the sacrum (20%), elbow (11%), back (7%) and ischial tuberosities (7%). Sixty (80%) were acquired while hospitalized. Age-adjusted multivariate analyses found that the risk factors significantly associated with pressure sores were Braden score< or =15 (OR=5.9, 95% CI: 2.4-13.7, p<0.0001) and previous pressure sores (OR=5.0 95% CI: 2.2-11.6, p<0.0001). Eleven sores (24.5%), mostly stage III and IV, were colonized by multiple-drug-resistant bacteria (i.e., methicillin resistant Staphylococcus aureus, extended spectrum beta-lactamase Enterobacteriaceae). Seven (9.3%) of the 75 ulcers were diagnosed only during the survey, by the experts; of the 68 diagnosed before the survey, 57 (83.8%) had been under treatment. Treatment was considered inappropriate according to French guidelines in 31.6% of the cases.

CONCLUSION

This prospective prevalence study resulted in better awareness of the patients at risk for pressure sores. It also made the recently created mobile geriatrics unit better known within the hospital.