Incidence of pressure ulcers in a neurologic intensive care unit

Effectiveness of instituting a specific bed protocol in reducing complications associated with bed rest

Pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia are well-known complications of bed rest. This retrospective, single-center, observational cohort study evaluated the effectiveness of instituting bed rest protocol that included specific positioning, continuous heel off-loading, recumbent upper and lower body bed exercises, scheduled incentive spirometry, frequent position changes, and thromboprophylaxis (chemical, mechanical, or both), in reducing the incidence of pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia in consecutive patients admitted for at least 7 days. A total of 29 patients (24 males, 5 females) were included in this study, with a mean age of 62.5 (median 63, range 17 to 84) years. The mean length of bed rest was 13.1 (median 10, range 7 to 31) days; and, the mean length of hospital stay was 21.1 (median 17, range 8 to 72) days. During hospitalization, 2 (6.9%) patients developed one or more of the complications measured, with 1 developing a posterior heel pressure ulcer that resolved with local care and another who developed deep venous thrombosis without pulmonary embolism, managed with therapeutic anticoagulation, and hospital-acquired pneumonia treated with antibiotic therapy. The results of this analysis were favorable in comparison with previously reported incidence rates for pressure ulcer, deep venous thrombosis, and hospital-acquired pulmonary complications in patients with similar risk factors, and suggested that a prescribed bed protocol reduces complications associated with bed rest.

A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients

BACKGROUND

Data on the prevention and treatment of pressure ulcers (PU's) among ICU patients is sparse.

OBJECTIVE

To compare PU outcomes in medial ICU patients nursed on either a reactive mattress overlay (ROHO, ROHO Inc, Belleville, IL, USA) or an active alternating pressure mattress (NIMBUS3, ArjoHuntleigh, Luton Bedfordshire, UK).

DESIGN

Pilot prospective single blind randomised controlled clinical trial.

INTERVENTION

Two types of pressure redistributing mattress.

PATIENTS

Two groups of eight patients.

METHODS

Patients included in the study were those at high risk (Norton scale <8) or with a PU on admission.

RESULTS

The two groups had similar patient characteristics. However, the NIMBUS 3 group presented with more ulcers per patient on admission (62.5%) and more severe ulcers (20% category 3) while four patients (50%) presented with a single superficial ulcer in the ROHO group. HEALING: The progress of the ulcers showed significant decreases in PU surface area (p=0.05), total PUSH tool score (p=0.01) in the NIMBUS 3 group compared to the ROHO group. In the NIMBUS 3 group 82% of the ulcers improved versus none in the ROHO group (p=0.002) and 18% remained stable versus 33%. None of the ulcers deteriorated in the NIMBUS 3 group versus 67% in the ROHO group (p=0.006). Full thickness wounds (Category 3) were present in 22% of the NIMBUS 3 group versus 0% of the ROHO group on admission and in 0% versus 66.7% (p=0.008) respectively at the end of the pilot study.

PREVENTION

Non-blanching erythema occurred equally in both arms at baseline; skin remained intact for the NIMBUS 3 group while 50% in the ROHO group worsened with superficial tissue loss.

CONCLUSION

This small pilot study suggests that 'active' alternating therapy is a useful adjunct in the care of highly vulnerable patients, while the outcomes may be less favourable when using 'reactive', constant low pressure devices.

Pressure ulcer incidence and risk factors in ventilated intensive care patients

PURPOSE

The aim of this study was to determine the incidence of pressure ulcers (PUs) in ventilated patients in all intensive care units (ICUs) in Granada (Spain) and identify risk factors for their development.

MATERIALS AND METHODS

A prospective cohort study in 9 medical-surgical ICUs was conducted. Two hundred ninety-nine patients with more than 24 hours on mechanical ventilation (MV) were enrolled during 2 periods in a 5-month study. Pressure ulcers of patients were measured according to the European Pressure Ulcer Advisory Panel.

RESULTS

Of the 299 patients initially enrolled, 47 (16%) developed PUs of at least grade II severity. The incidence density of PUs was 13.4 cases per 1000 patient-days of ICU stay and 19.6 cases per 1000 patient-days on MV. Logistic regression identified first-day respiratory sequential organ failure assessment (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.026-2.360; P = .037), fourth-day cardiovascular sequential organ failure assessment (OR, 1.33; 95% CI, 1.066-1.664; P = .012), age (OR, 1.042; 95% CI, 1.013-1.072; P = .004), winter period (OR, 4.60; 95% CI, 1.99-10.59; P < .001), and length of MV before PUs (OR, 1.042; 95% CI, 1.005-1.080; P = .024) as significant independent predictors of PU development.

CONCLUSIONS

Among other factors previously known in ventilated patients, duration of MV and winter period were identified as risk factors for PUs.

Prospective study: reducing pressure ulcers in intensive care units at a Turkish medical center

PURPOSE

The purpose of this study was to determine the impact of an educational intervention on the incidence of stage II pressure ulcers (PUs) in adult patients in intensive care units (ICUs) in a Turkish medical center.

DESIGN

This was a prospective study of patients admitted to ICUs. Data were collected over a 3-month period. Subjects were assessed using the Braden Scale for Predicting Pressure Sore Risk to determine the risk for developing a PU; assessment was completed within the first 24 hours of admission and each 48 hours thereafter for a maximum of 12 weeks. Educational intervention was employed: Intervention included education of ICU nurses about PU prevention and risk assessment; and following the educational intervention and implementation of the PU prevention protocol in all ICUs, data were collected for study period II.

SUBJECTS AND SETTING

The sample comprised 186 patients admitted to critical care units of a Turkish medical center. Ninety-three subjects participated in a preintervention comparison group, and 93 subjects participated in an intervention group.

INSTRUMENTS

Data were collected using a demographic and clinical data form, a nursing intervention checklist, and the Braden Scale for Predicting Pressure Sore Risk.

RESULTS

Stage II PUs were observed in a total of 50 patients for the overall sample. The most common site was the sacrococcygeal area, which accounted for 46% of ulcers. A statistically significant difference was observed when the rate of stage II PUs in the comparison group, 37% (34 of 93 patients), was compared to the rate in the intervention group, 17% (16 of 93 patients) (chi2 = 8.86, df = 1, P < .01).

CONCLUSION

Education regarding preventive care can be effective in reducing the incidence of PUs in the ICU setting. Therefore, education about risk assessment and PU prevention should be a priority for nurses in critical care settings.

Using the Braden and Glasgow scales to predict pressure ulcer risk in patients hospitalized at intensive care units

Pressure ulcers remain a major health issue for critical patients. The purpose of this descriptive and exploratory study was to analyze the risk factors for the development of pressure ulcers in patients hospitalized at an intensive care unit of a university hospital. Patients were assessed through the Braden scale to determine the risk for the development of pressure ulcers and to identify individual risks, and the Glasgow scale was used to assess their consciousness. It was found that the risks associated with pressure ulcer development were: low scores on the Braden Scale on the first hospitalization day and low scores on the Glasgow scale. The results showed that these tools can help nurses to identify patients at risk, with a view to nursing care planning.

Incidência de úlcera por pressão e ações de enfermagem

OBJETIVOS: Estimar a incidência cumulativa (ICup) e a densidade de incidência (DIup) de úlcera por pressão (UP) e descrever a ocorrência de ações de enfermagem em dois hospitais do Estado da Bahia, antes (fase 1) e durante (fase 2) intervenção educativa. MÉTODOS: Estudo de coortes prospectivo com pacientes médico-cirúrgicos, utilizando avaliação da integridade cutânea, consulta a registros no prontuário, e entrevista com paciente, família e equipe. RESULTADOS: ICup, fase 1 e fase 2 foi, respectivamente, no hospital 1 de 31,4% e 13,6%, e no hospital 2, de 21,4% e 15%; DIup aponta tempo médio de exposição para aparecimento de UP no hospital 1 de 14,3 dias na fase 1 e de 43,5 na fase 2; no hospital 2, de 31,3 dias na fase 1 e 37 na fase 2. CONCLUSÃO: Redução estatisticamente significante da DIup no hospital 1; cuidados de enfermagem preventivos para UP comprometidos em ambos os hospitais nas duas fases.

Incidência de úlcera por pressão em pacientes neurocirúrgicos de hospital universitário

OBJETIVO: Conhecer a incidência de úlcera por pressão no pré e pós-operatório de pacientes neurocirúrgicos e descrever as medidas preventivas implementadas pela equipe de enfermagem durante nesses períodos. MÉTODOS: Estudo de Coorte prospectivo realizado na unidade de neurocirurgia do Hospital São Paulo. Foram incluídos pacientes submetidos a cirurgias eletivas do sistema nervoso central e que não apresentaram úlcera por pressão na internação. RESULTADOS: Foram avaliados 60 pacientes sendo que 34 (56,6%) do sexo feminino. A mediana da idade foi de 49 anos, com variação de 19 a 78 anos. Oito (13,4%) pacientes desenvolveram nove úlceras por pressão. Dos pacientes de risco para úlcera por pressão, três (25%) no pré-operatório, 33 (66%) no pós-operatório imediato e 13 (86,6%) no pós-operatório mediato tinham medidas de prevenção para úlcera por pressão. CONCLUSÃO: A incidência de úlcera por pressão foi de 13,3%. Há necessidade de implantação de programas de prevenção, com a finalidade de diminuir a úlcera por pressão em pacientes neurocirúrgicos.

Incidence and risk factors for pressure ulcers in the intensive care unit

AIMS

To determine the incidence of pressure ulcers occurring at least 48 hours after admission and risk factors for pressure ulcers grade 2-4 in a long-stay surgical Intensive Care Unit (ICU) population.

BACKGROUND

The incidence of pressure ulcers in intensive care units is larger than in non-intensive environments.

DESIGN

Prospective descriptive research design.

METHODS

Using pressure ulcers grade 2-4 as an outcome measure, a multivariate logistic regression analysis was used to identify the risk factors. Data were obtained on a daily basis in a surgical intensive care unit of the University Hospital Leuven between November 2003-March 2004. A total of 520 long-stay (>or= 24 hours) intensive care patients were included.

RESULTS

Cumulative incidence of pressure ulcers grade 2-4 was 20.1%. The following variables were positively associated with pressure ulcers grade 2-4: history of vascular disease, treatment with Dopamine or Dobutamine, intermittent haemodialysis (IHD) or continuous veno-venous haemofiltration (CVVH), mechanical ventilation. Also preventive measures were statistically positively associated with pressure ulcers grade 2-4: turning, floating heels, alternating mattresses, adequate prevention. The use of sedatives, body temperature above 38.5 degrees C and sitting in chair where negatively associated with pressure ulcers. Pressure ulcers are statistically associated with different risk factors and preventive measures.

CONCLUSION

The identified risk factors are eligible to be included in a new risk assessment scale for patients admitted to intensive care units.

RELEVANCE TO CLINICAL PRACTICE

The novel insights have implications for risk assessment for patients in intensive care units. Patients admitted to intensive care units have other risk factors for pressure ulcers which are eligible to be included in a new risk assessment scale.

A national prevalence study of pressure ulcers in French hospital inpatients

OBJECTIVE

To ascertain pressure ulcer prevalence rate in French hospitals.

METHOD

In 2004, a cross-sectional study was conducted in all French hospitals, except university hospitals. The National Pressure Ulcer Advisory Panel (NPUAP) staging was used. Data were collected using two self-administered questionnaires.

RESULTS

A total of 37,307 inpatients in 1170 wards in 1149 hospitals were assessed, representing a response rate of 93.5%. Their mean age was 72.3 years and 62% were females. In all, 3314 patients had at least one pressure ulcer, giving a prevalence rate of 8.9%. A total of 4991 pressure ulcers were recorded; 64% of the patients had only one pressure ulcer. Fifty-five per cent of the patients had at least two concomitant diseases. When patients with only one ulcer were assessed, the most common locations were the heels (53%) and sacrum (29%). Heel pressure ulcers were more common in patients with obliterative arterial disease, and sacral pressure ulcers were more frequent in incontinent (urine, faecal and double incontinence) patients. Patients with multiple pressure ulcers had more severe lesions.

CONCLUSION

These results indicate that the prevalence of pressure ulcers in French hospital inpatients has remained stable since the last prevalence study undertaken 10 years before, when the rate was 8.9%. Such studies should be encouraged in all health-care settings as a means of improving the care provided.

Prevention and treatment of pressure ulcers in the surgical intensive care unit

PURPOSE OF REVIEW

To review recent work on pressure ulcer prevention and treatment in the intensive care unit within the context of previous work.

RECENT FINDINGS

Although pressure ulcerations are an age-old and relatively common problem, their pathophysiology, risk factors for their development, and treatment options lack complete understanding. Most of the available literature is based on noncritical care patient clinical experience in noncritical care journals. Previous estimates of pressure ulcer underestimate the problem in high-acuity intensive care units. Available risk factors in previously validated tools may not be accurate in the intensive care unit patient population. However, the current literature provides an initial footing for intensivists to improve their pressure ulcer prevention and treatment methods that will become increasingly important for clinical certification as well as research.

SUMMARY

Preventing and treating pressure ulcers will continue to be a troublesome problem for intensivists. Accurate assessments and comparisons remain problematic across a heterogeneous intensive care unit population. Risk stratification schema need tailoring to the problems of intensive care unit patients. Treatment modalities may not prevent all pressure ulcer development or extension. Available data support dedicated training of nurses and physicians to maximize local intensive care unit resources to minimize the impact of pressure ulceration.

Prevention of pressure ulcers: a descriptive study in 3 intensive care units in Turkey

PURPOSE

The aim of this descriptive study was to describe the level of preventive care provided to intensive care unit (ICU) patients at risk for development of pressure ulcers (PU).

SETTING AND SUBJECTS

Our study population comprised 126 nurses working at coronary ICU, cardiovascular surgery ICU, or a gastroenterology ICU of State Hospital in the Republic of Turkey. The study sample consisted of 30 nurses selected from these units using a layered sampling method.

INSTRUMENTS

Data were collected using the following 4 forms: (1) ICU evaluation form, (2) demographic questionnaire form, (3) Braden Scale, and (4) observation form. The observation form was developed by the investigator to record PU prevention interventions made by the study nurses.

METHODS

Nurses were observed while giving care to patients at risk according to Braden Scale scores and each action of the nurses to prevent PU was recorded. Data were collected until 90 observations (3 observations with each of 30 nurses) were completed.

RESULTS

Nurses did not consistently engage in interventions recommended for prevention of PU. Subjects did not consistently use the risk-evaluation scale, document position changes on the appropriate form, and train auxiliary personnel about PU prevention. The most frequently fulfilled behaviors for PU prevention were avoiding hot water when cleansing the skin, helping the patient eat, avoiding placing the patient directly on a trochanter, refraining from using improper support material, and use of pressure-redistribution surfaces. The least fulfilled behaviors were (1) application of a skin barrier or protectant on moist skin and (2) application of a moisturizer to dry or compromised skin, protecting the skin during patient transfer, repositioning, and documenting prevention interventions.

CONCLUSION

This study demonstrates that critical care nurses do not consistently provide preventive care for PU.

Intensive Care Nurses’ Knowledge of Pressure Ulcers: Development of an Assessment Tool and Effect of an Educational Program

Background Critically ill patients are at high risk for pressure ulcers. Successful prevention of pressure ulcers requires that caregivers have adequate knowledge of this complication.

Objective To assess intensive care nurses’ knowledge of pressure ulcers and the impact of an educational program on knowledge levels.

Methods A knowledge assessment test was developed. A cohort of registered nurses in a tertiary referral hospital in New Zealand had knowledge assessed 3 times: before an educational program, within 2 weeks after the program, and 20 weeks later. Multivariate analysis was performed to determine if attributes such as length of time since qualifying or level of intensive care unit experience were associated with test scores. The content and results of the assessment test were evaluated.

Results Completion of the educational program resulted in improved levels of knowledge. Mean scores on the assessment test were 84% at baseline and 89% following the educational program. The mean baseline score did not differ significantly from the mean 20-week follow-up score of 85%. No association was detected between demographic data and test scores. Content validity and standard setting were verified by using a variety of methods.

Conclusion Levels of knowledge to prevent and manage pressure ulcers were good initially and improved with an educational program, but soon returned to baseline.

Increasing heel skin perfusion by elevation

OBJECTIVE

To determine the efficacy of elevation in the primary prevention and treatment of pressure ulcers by studying the blood flow in tissue at risk of ulceration.

DESIGN

A prospective study was used to compare different preventative devices with an elevating prosthesis.

SETTING

: Wollongong Hospital Wollongong, New South Wales, Australia.

PARTICIPANTS

Normal subjects and subjects with vasculopathy were tested with their heel resting on a hospital bed, medical-grade lamb's wool, or a viscoelastic gel overlay, with or without the test prosthesis. Skin perfusion was measured throughout using a laser Doppler monitor.

INTERVENTION

A device designed to elevate the heel off the bed and distribute the weight of the leg and foot on the calf.

MAIN OUTCOME MEASURE

Heel capillary blood perfusion.

MAIN RESULTS

Perfusion in the heel was significantly greater when elevated than when using the other devices tested. The differences in mean red blood cell flux were significant, with P < .0001 for bed-normals, ie, subjects with no peripheral vascular disease on an alpha Xcell mattress overlay as the control with flux increasing from 7.6 to 163.1 arbitrary units (AU); P < .005 bed-vasculopathy, ie, subjects with peripheral vascular disease on an alpha Xcell mattress overlay as the control with flux increasing from 31.6 to 224.7 AU; P < .0001 viscoelastic overlay subjects where the viscoelastic overlay was the control with flux increasing from 26.6 to 291.4 AU; and P < .01 lamb's wool subjects where the lamb's wool was the control with flux increasing from 27.7 AU to 169.2 AU.

CONCLUSION

In this study, when the heels were elevated, tissue perfusion to that area was substantially increased. When the heel was transferred to the elevating splint, the heel capillary bed underwent reactive hyperemia, indicating the alleviation of tissue hypoxia. Elevation is therefore an important technique in pressure ulcer prevention and treatment and should be incorporated into health care practice.

Pressure ulcer risk assessment immediately after cardiac surgery--does it make a difference? A comparison of three pressure ulcer risk assessment instruments within a cardiac surgery population

The intensive care unit (ICU) population has a high risk of developing pressure ulcers. According to several national expert guidelines for pressure ulcer prevention, a risk assessment for every situation in which the patient's condition is changing should be performed using a standardized risk assessment instrument. The aims of this study were to (a) assess the number of patients who are 'at risk' for the development of pressure ulcer according to three commonly used risk assessment instruments in the intermediate period after cardiac surgery procedures, (b) assess which instrument best fits the situation of the ICU patients and c) decide if 'static' risk assessment with an instrument should be recommended. The modified Norton scale, the Braden scale and the 4-factor model were used in a convenience sample of 53 patients to assess the risk for development of pressure ulcer in the first 5 days (in ICU) after cardiac surgery procedures. The number of patients at risk were >60% by the 4-factor model, >70% by the modified Norton scale and >80% by the Braden scale. Sensitivity and specificity in all scales were not satisfactory. Forty-nine per cent (n= 26) of the patients developed a pressure ulcer in the operating room, 13% (n= 7) up to day 5 in the cardiac surgery ICU. Only 1.9% (n= 1) of the pressure ulcers were stage 2. The study concluded that the patients in the cardiac surgery ICU can be identified as at risk during the first 5 days after surgical procedure without continuously using a standardized risk assessment instrument in every changing condition. Individual risk assessment by a standardized risk assessment instrument is only recommended to enable initiation of preventive measures based on patient-specific risk factors.

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 effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting

The Braden score is a reliable predictor of a patient's potential for developing pressure ulcers. Moisture is 1 of 6 indicators considered when calculating a Braden score. Efforts to reduce the effects of moisture and enzymatic activity on skin from incontinent diarrhea have employed various types of nonstandardized and nonapproved approaches. Rigid rectal tubes and catheters designed for other purposes are among the devices being utilized. These devices may put the patient at risk for rectal necrosis and loss of sphincter tone, and their use has produced no demonstrable positive outcomes. Additionally, their use is limited to those patients who are experiencing active diarrhea. The Zassitrade mark Bowel Management System (BMS) developed by Zassi Medical Evolutions, Inc., has produced promising outcomes. While the BMS is useful in managing patients with diarrhea, it can also be used to modify formed stool in patients who have wounds that are likely to become contaminated with incontinent feces, or who are too hemodynamically unstable to turn for lengthy or frequent incontinence care.

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.

Epidemiology, risk and prevention of pressure ulcers in critically ill patients: a literature review

New nursing interventions and pressure-redistributing devices in intensive care units, and specific risk factors affecting critically ill patients, mean that different factors must be taken into consideration in preventing pressure ulcers.

[Decubitus ulcer and nutritional status: literature review]

In order to better understand aspects related to the nutritional assessment of patients in risk for pressure ulcers, we reviewed the national and international literature indexed on Medline and LILACS bibliographic databases, from 1987 to 2001. The aim of this research was to investigate the knowledge production on pressure ulcers and nutritional status, as well as to learn about the authors and the publication focus. We concluded that patients in risk for pressure ulcers can be early identified based on nutritional assessment, including biochemical data, anthropometric evaluation, clinical data, diet history and energetic consumption. The alterations are frequent in elderly patients, hospitalized patients, patients with a chronic disease such as a vascular cerebral accident, cancer and spinal cord injury.

[Incidence of pressure ulcers at a university hospital]

This study aimed to identify the incidence of pressure ulcers (PU) at São Paulo University Hospital--Brazil, as well as to establish possible associations with patients' sociodemographic and clinical characteristics. Data were collected during three months, involving 211 risk patients, resulting in a 39.8% incidence level. A significant statistical correlation (p<0.05) was found between incidence level and age and PU area; and between age and humidity, time of hospitalization and nutrition, PU area and nutrition. Results indicate the urgent need to implant a PU prevention and treatment program at the institution and provide methodological contributions for other services to develop this kind of research.

Critical rehabilitation of the patient with spinal cord injury

Most healthcare practitioners have worked with patients with spinal cord injury at some point in their career, for some it is a specialty. The critical care area usually only has patient with spinal cord injury for a brief time before they are transferred. More recently, there are longer intensive care unit stays due to multiple trauma and lack of insurance. Nurses must be cognizant of indications, contraindications, and best practice interventions to contribute positively to patient's long-term outcomes. As part of the multispecialty team, nurses can be pivotal in preventing secondary complications, especially pressure ulcers. Rehabilitation team members can be consulted early to provide expertise in managing this complex diagnostic group.

Predicting pressure ulcer risk with the modified Braden, Braden, and Norton scales in acute care hospitals in Mainland China

The aim of this study was to develop a modified Braden scale, to evaluate its predictive validity, and to identify a more valid pressure ulcer risk calculator for application in acute care hospitals in Mainland China among the modified Braden, Braden, and Norton scales. The initial modified Braden scale, with the addition of skin type and body build for height, was proposed in this study. Four hundred twenty-nine subjects who were admitted to two acute care hospitals in Mainland China within 24 hr and free of pressure ulcers upon admission were assessed with the initial modified Braden, Braden, and Norton scales by three nurse assessors. This was followed by a daily skin assessment to note any pressure ulcer by a nurse assessor. Nine subjects had pressure ulcers detected at Stages I (89%) and II (11%) after an average stay of 11 days. The descriptive analysis of each subscale scoring item in the initial modified Braden scale indicated that skin type and body build for height were the most distinct predictive factors whereas nutrition was the least distinct factor for predicting pressure ulcer development. Based on these findings, the modified Braden scale was further developed with the addition of skin type and body build for height and by exclusion of nutrition. The predictive validity test reported that the modified Braden scale demonstrated a better balance of sensitivity (89%) and specificity (75%) at a cutoff score of 16, with a higher positive predictive value (7%), than the Braden and Norton scales. This finding revealed that for this sample, the modified Braden scale is more effective in pressure ulcer risk prediction than the other two scales. Because the modified Braden scale is not 100% sensitive and specific, to increase clinical efficacy in the prevention of pressure ulcer, it is recommended that it be adopted combined with nursing judgment to predict pressure ulcer development in acute care settings in Mainland China.

Research Comparing Three Heel Ulcer-Prevention Devices

OBJECTIVE

To compare 3 pressure-reduction devices for effectiveness in prevention of heel ulcers in moderate-risk to high-risk patients.

DESIGN

A prospective quasi-experimental 3-group design was used.

SETTING AND SUBJECTS

A sample of 338 "moderate-risk to high-risk" adult inpatients, ages 18 to 97, at 2 medical centers in South Texas were studied.

INSTRUMENTS

The Braden Scale for Pressure Ulcer Risk and investigator-developed history and skin assessment tools were used.

METHODS

Subjects were randomly assigned to the High-Cushion Kodel Heel Protector (bunny boot), Egg Crate Heel Lift Positioner (egg crate), or EHOB Foot Waffle Air Cushion (foot waffle). Data are demographics, Braden scores, comorbidities, skin assessments, lengths of stay, and costs of devices. Analyses were Chi-square, analysis of variance, and regression.

RESULTS

Of 240 subjects with complete data, 77 (32%) were assigned to the bunny boot group, 87 (36.3%) to the egg crate, and 76 (31.7%) to the foot waffle. Twelve ulcers developed in 240 subjects (5% incidence). Six subjects had only 1 foot. Eleven ulcers were Stage I (nonblanchable erythema), and 1 was Stage II (partial thickness). Overall incidence was 3.9% for the bunny boot, 4.6% for the egg crate, and 6.6% for the foot waffle (not significantly different among groups). The bunny boot with pillows was most cost effective (F[3], N = 240) = 1.342, p <or= .001).

CONCLUSIONS

In this study, the bunny boot was as effective as higher-tech devices. The results, however, were confounded by nurses adding pillows to the bunny boot group.

The relationship between dermal pressure ulcers, oxygenation and perfusion in mechanically ventilated patients

BACKGROUND

More than 1.5 million hospitalized patients develop dermal pressure ulcers (DPUs) annually, which increases cost and prolongs length of stay. Mechanically ventilated patients may be at a high risk for DPU development, but research has not focused on the prevalence of dermal pressure ulcers in this population or the factors associated with dermal pressure ulcer development.

OBJECTIVES

To determine the prevalence of dermal pressure ulcers in subjects receiving mechanical ventilation and to describe the relationship between systemic oxygenation, tissue perfusion, and the prevalence of dermal pressure ulcers.

METHODS

Subjects from an Intensive Care Unit in a Midwestern hospital in the United States were recruited into this descriptive, correlational study following intubation. Variables included: demographics, general subject status (weight, serum albumin), ventilatory status, oxygenation status (arterial blood gas analysis including concentration of hydrogen ions, partial pressure of carbon dioxide, partial pressure of oxygen, and amount of oxygen carried by hemoglobin), perfusion status (mean arterial pressure, heart rate, urine output), and skin condition. The Braden Scale was used to measure the risk of skin breakdown, with any skin breakdown being classified in stages ranging from I to IV (I having minimal breakdown, IV having maximal breakdown). Braden Scores range from 6 to 23, with a score of 6 indicating high risk and a score of 23 indicating low risk. Data were collected every other day after admission to the Medical Intensive Care Unit until extubation, transfer, or death.

RESULTS

Subjects (n = 40) were primarily Caucasian (77.5%), having a mean age of 56.4 years (+/-14.6 years). Half of the sample was male (50%). Twenty percent of the sample developed DPUs. A Pearson's correlation identified the significant associations between the Braden Score and MAP, PaCO(2), largest weight fluctuation in a 3-day period, and change in weight from admission to discharge. Surprisingly, the lowest Braden Score was not significantly associated with the development of DPUs.

CONCLUSIONS

Mechanically ventilated patients are vulnerable to developing dermal pressure ulcers as evidence by 20% of the subject population developing a dermal pressure ulcer. The most significant factors related to a low Braden Score in this group are fluid shifts and fluid weight gain. This may be an important predictor of dermal pressure ulcers not currently assessed clinically.

Elevated sacral skin temperature (Ts): a risk factor for pressure ulcer development in hospitalized neurologically impaired Thai patients

Pressure ulcer incidence and sacral skin temperature (T(s)) were measured in hospitalized neurologically impaired Thai patients ( n = 17) positioned supine and then laterally. Pressure ulcer incidence within 2 weeks of admission was 47%. Regardless of reclining position, mean sacral T(s) in subjects who developed a pressure ulcer was higher ( p < .01) than those who did not develop an ulcer. The data suggest that T(s) may increase at least 1.2 degrees C 24-96 hr before sacral pressure ulcer development. Sacral T(s) may be an objective predictor of sacral pressure ulcer development in hospitalized neurologically impaired Thai patients.

Evaluación de la calidad de los cuidados en la UCI a través de un plan de atención de enfermería informatizado

The computerized systems that are being implemented for the recording of the Nursing Care Plan may facilitate the performance of continuing follow-up of the care quality. This retrospective descriptive study has been performed in a polyvalent Intensive Care Unit with the following objectives: a) describe the evaluation of the care quality, performed through the computerized record of the Nursing Care Plan; and 2) compare this evaluation with that performed in 1998, when the Nursing Care Plan had not yet been computerized. In the 98 revised computerized Nursing Care Plans, corresponding to the same number of patients with a mean stay of 13.8 days, the following results were obtained. Artificial airway. 74 patients had an endotracheal tube with a mean stay of 5.4 days, 11 patients had a cannula tracheotomy (time period of 45.7 days); no events occurred. Central venous lines: 91 patients were carriers of 163 catheters, the mean presence time was 9.9 days; three with withdrawn due to obstruction, there was one accident withdrawal and two were self-removed. Arterial catheter: the total number of arterial lines, corresponding to 87 patients, was 101 with a mean presence of 6.7 days; 15 obstructions, six accidental withdrawals and four self-removals were recorded. Bladder catheter: 91 patients had a bladder catheter (mean presence 12.9 days); no event occurred. Nasogastric tube: 83 patients were carriers of 98 tubes (63 Salem type and 35 for nutrition), with a mean presence of 10.1 days; five were withdrawn due to obstruction, three accidental withdrawals and 40 self-removed (23 in one patient). Skin integrity: nine patients developed bedsores, eight grade II and two grade III, the mean stay was 26.6 days. No patients had an accidental fall. As study conclusions, it stands out that the preestablished standards for the evaluation of the care were achieved in most and the care quality is maintained in relationship with our 1998 study, remaining within a level considered as good.

Special issues in plastic and reconstructive surgery

Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.

[The use of water to seal facial mask for non invasive ventilation reduces the incidence of pressure ulcers]

To demostrate that the use of water to seal facial mask for non invasive ventilation (NIV) reduces the incidence of facial pressure ulcers.

METHODS

prospective study including 47 pacients who (according to their responsable physician) needs NIV. Intersurgical facial mask and Puritann Bennet 7200 ventilator are used. Facial mask interface is randomly filled with water or air. Risk factors for pressure ulcers, lenght oftime of NIV (TNIV) and when the facial ulcer appears (TUA) are recorded. Student's T test is used to compare menas (except by TUA, analized with Mann-Whitney test). For qualitative variables X2 is eused. Data are presented as mean standard desviation (for TUA mean [range]).

RESULTS

We studied 23 patients in the air group (AG) and 2 patients in the water group (WG), whose mean age was 73 years and APACHE II of 13. there where no differences studied in risk factors between groups (proteins 5.6 0.8 in AG vs 5.7 1.4 g/dl; PEEP 5 2 vs 6 1 cm of water; diabetes 11 vs 10; Nasogastric tube 7 vs 6; inotropics 9 vs 6 patients). TNIV was similar between groups (884 1,092 vs 875 1,107 minutes). 39% of patients in AG and 25% in WG developed facial ulcers (p = NS), with mean TUA of 847 minutes.

CONCLUSIONS

The use of water to seal facial mask during invasive non ventilation dealays the appearance of facial ulcers. More studies are needed to demostrate significant reduction in the incidence of ulcers.