Risk factors for pressure ulceration in a resource constrained spinal injury service

Attitude and preventive practices of pressure ulcers among orthopedic nurses in a tertiary hospital in Ghana

BACKGROUND

Pressure ulcers (PUs), which affect millions of people worldwide, are among the five most prevalent hospitalized cases causing adverse impairment. Nevertheless, pressure ulcers are largely preventable, and their management depends on their severity. The authors, therefore, explored the attitude and preventive practices of pressure ulcers among orthopedic nurses in a tertiary hospital in Ghana.

METHODS

An exploratory descriptive qualitative approach was employed for this study to help researchers explore the attitude and practices toward PU (Pressure Ulcer). Purposive sampling approach was employed, and data was analyzed using thematic content analysis. The sample size for this study was 30 which was obtained based on saturation. Participants were engaged in face-to-face interviews which were transcribed verbatim.

FINDINGS

Two themes and eight subthemes were generated from the analysis of this study. The two themes were preventive practices and attitude towards PU. The study identified that there were no specific protocols illustrated on the wards for managing pressure ulcers. Nevertheless, the study participants were keen on preventing pressure ulcers and hence engaged in practices such as early patients' ambulation, early identification of PU signs, removing creases and crumps from patient beds, nutritional management for PU prevention, and dressing of PU wounds.

CONCLUSION

Practices of pressure ulcer management were highly valued by the orthopedics nurses. Hence, the nurses recommended the need for accepted guidelines on pressure ulcer management to be illustrated in the various orthopedic wards in the country.

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data

PURPOSE

To identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs) METHODS: Data were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) centers from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015-2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Altogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR 3.06, 95% CI 1.55-6.03, p = 0.001), and number of days in the ICU (OR 1.06, 95% CI 1.04-1.09, p < 0.001) maintained significance.

CONCLUSIONS

These data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.

Dietetics After Spinal Cord Injury: Current Evidence and Future Perspectives

Following spinal cord injury (SCI), individuals are at high risk for obesity and several chronic cardiometabolic disorders due to a deterioration in body composition, hypometabolic rate, and endometabolic dysregulation. Countermeasures to the consequences of an SCI include adopting a healthy diet that provides adequate nutrition to maintain good body habitus and cardiometabolic health. A proper diet for individuals with SCI should distribute carbohydrates, protein, and fat to optimize a lower energy intake requirement and should stress foods with low caloric yet high nutrient density. The purpose of this article is to present available evidence on how nutritional status after SCI should advance future research to further develop SCI-specific guidelines for total energy intake, as it relates to percent carbohydrates, protein, fat, and all vitamins and minerals, that take into consideration the adaptations after SCI.

Incidence of Pressure Injury in Individuals With Spinal Cord Injury: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this systematic review and quantitative analysis of pooled data was to assess the global incidence of pressure injury (PI), across time frames and countries, in individuals with spinal cord injury (SCI).

DESIGN

Systematic review and meta-analysis.

SEARCH STRATEGY

PubMed, Web of Science, and EMBASE databases were systematically searched for studies published from database inception to January 2019, with only English language studies that reported the incidence of PIs in individuals with SCI were included. Study quality was assessed by a 14-item standardized checklist. We calculated the incidence of PIs as the number of new PIs in individuals with SCI and the total number of individuals with SCI during the study period. Findings are presented as incidence rate with 95% confidence intervals (CIs).

RESULTS

The search yielded 1652 studies; after studies were reviewed for inclusion criteria, 29 studies representing N = 82,722 patients were retained for data extraction. The global incidence of PIs was 0.23 (95% CI, 0.20-0.26). Data for regional distribution by country showed a pooled incidence of 0.43 (95% CI, 0.28-0.57) in individuals with SCI in South American countries, 0.36 (95% CI, 0.16-0.56) in African countries, 0.25 (95% CI, 0.14-0.37) in European countries, 0.23 (95% CI, 0.19-0.27) in North American countries, and 0.16 (95% CI, 0.06-0.25) in Asian countries. The incidence was 0.22 (95% CI, 0.19-0.26) in developing countries versus 0.27 (95% CI, 0.17-0.37) in developed countries. From 2000 to 2009, the incidence of PIs in individuals with SCI was 0.28 (95% CI, 0.09-0.47). The incidence rate of PIs before 2000 and after 2009 was 0.23. The hospital- and community-acquired PI incidence was 0.22 (95% CI, 0.19-0.26) and 0.26 (95% CI, 0.20-0.32), respectively.

CONCLUSIONS

Study findings indicate that more than 1 in 5 individuals with SCI will develop a PI. Individuals with SCI are at high risk of developing PI, especially in community settings or low- and middle-income developing countries. The findings highlight the importance of further investigation of risk factors and prevention and management strategies for PIs in individuals with SCI.

Prevalence of pressure ulcers in africa: A systematic review and meta-analysis

BACKGROUND

A recent global review of pressure ulcers contained no studies from Africa.

OBJECTIVE

To identify the prevalence and incidence of pressure ulcers in Africa.

DATA SOURCES

Bibliographic databases, African specific databases, grey literature.

STUDY ELIGIBILITY CRITERIA

Studies with prevalence or incidence data of pressure ulcers from Africa since the year 2000.

PARTICIPANTS

Any age, including children, in any setting, specifically including hospital patients from any clinical area but not restricted to hospital settings.

STUDY APPRAISAL AND SYNTHESIS METHODS

Hoy score for bias, Joanna Briggs Institute Critical Appraisal Instrument.

METHOD

We followed the PRISMA guideline for systematic reviews. We searched Embase, Medline, Scopus, CINHAL, Google Scholar, specialist African databases and grey literature for studies reporting incidence or prevalence data.

RESULTS

Nineteen studies met the inclusion criteria and were included in the study. Point prevalence rates varied from 3.4% to 18.6% for medical/surgical and other general hospital units with a pooled prevalence of 11%, for grades II-IV 5%. For spinal injury units the pooled prevalence was 44%.

LIMITATIONS

restricted to English, French and Arabic.

CONCLUSION

Prevalence of pressure ulcers in Africa reported here is similar to figures from a recent review of prevalence in Europe and two recent global reviews of hospitalised patients. Prevalence of pressure ulcers in spinal cord injury patients is similar to figures from a review of developing countries. The reporting of prevalence is lacking in detail in some studies. Studies using an observational design employing physical examination of patients showed higher prevalence than those relying on other methods such as medical notes or databases.

IMPLICATIONS OF KEY FINDINGS

Further prevalence and incidence studies are needed in Africa. Reporting of such studies should ensure items in the "Checklist for Prevalence Studies" from Joanna Briggs Institute (or similar well regarded resources) are addressed and the PICOS model and PRISMA guidelines are employed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Prospero registration number CRD42020180093.

Pressure ulcers after traumatic spinal injury in East Africa: risk factors, illustrative case, and low-cost protocol for prevention and treatment

STUDY DESIGN

Retrospective, case-control study.

OBJECTIVES

In a traumatic spinal injury (TSI) cohort from Tanzania, we sought to: (1) describe potential risk factors for pressure ulcer development, (2) present an illustrative case, and (3) propose a low-cost outpatient protocol for prevention and treatment.

SETTING

Tertiary referral hospital.

METHODS

All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, time to hospital, injury characteristics, operative management, length of hospitalization, and mortality. Pressure ulcer development was the primary outcome. Regressions were used to report potential predictors, and international guidelines were referenced to construct a low-cost outpatient protocol.

RESULTS

Of 267 patients that met the inclusion criteria, 51 developed a pressure ulcer. Length of stay was greater for patients with pressure ulcers compared with those without (45 vs. 30 days, p < 0.001). Potential predictors for developing pressure ulcers were: increased days from injury to hospital admission (p = 0.036), American Spinal Injury Association Impairment Scale grade A upon admission (p < 0.001), and thoracic spine injury (p = 0.037). The illustrative case described a young male presenting ~2 months after complete thoracic spinal cord injury with a grade IV sacral pressure ulcer that lead to septic shock and death. Considering the dramatic consequences of pressure ulcers in lower- and middle-income countries (LMICs), we proposed a low-cost protocol for prevention and treatment targeting support surfaces, repositioning, skin care, nutrition, follow-up, and dressing.

CONCLUSIONS

Pressure ulcers after TSI in LMICs can lead to increased hospital stays and major adverse events. High-risk patients were those with delayed presentation, complete neurologic injuries, and thoracic injuries. We recommended aggressive prevention and treatment strategies suitable for resource-constrained settings.

The global burden of pressure ulcers among patients with spinal cord injury: a systematic review and meta-analysis

BACKGROUND

Pressure ulcers (PU), one of the common challenging public health problems affecting patient with spinal cord injury. PUs occurs over bony areas of the body where pressure and tissue distortion is greatest. It has a significant impact to the patient and health care system. Moreover, it has psychological, physical, social burden and decrease the quality of life (QoL) of patients. Despite its serious complications, limited evidence is available on the global magnitude of pressure ulcers among patient with spinal cord injury. Hence, this review and meta-analysis aimed to estimate the global magnitude of pressure ulcers among patient with spinal cord injury.

METHODS

PubMed, Scopus, Google Scholar, African Journals Online, PsycINFO, and Web of Science were systematically searched to retrieve related articles. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was followed. DerSimonian and Laird random-effects model was applied to obtain the pooled effect size. To investigate heterogeneity across the included studies, I2 test was employed. Publication bias was examined using funnel plot and Egger's regression test statistic. Sensitivity analysis was deployed to see the effect of a single study on the overall estimation. Analysis was done using STATA™ Version 14 software.

RESULTS

A total of 24 studies which comprises of 600,078 participants were included in this study. The global pooled magnitude of pressure ulcers among patients with spinal cord injury was 32.36% (95% CI (28.21, 36.51%)). Based on the subgroup analysis, the highest magnitude of pressure ulcer was observed in Africa 41.19% (95% CI: 31.70, 52.18).

CONCLUSION

This systematic review and meta-analysis revealed that about one in three patients with spinal cord injury had pressure ulcers. This implies that the overall global magnitude of pressure ulcer is relatively high. Therefore, policy maker and other concerned body should be design country context- specific preventive strategies to reduce the burden of pressure ulcers in patients with spinal cord injury.

Demonstrating the Potential of Using Transcutaneous Oxygen and Carbon Dioxide Tensions to Assess the Risk of Pressure Injuries

Pressure injuries have a high incidence in elderly and critically ill patients, and can endanger lives in severe cases. The key to reducing the incidence of pressure injuries is to find an objective, noninvasive, automatic and consistent scientific method for assessing pressure injuries. To serve this need, we conducted a clinical study to investigate the potential of using transcutaneous oxygen tension (TcPO2) and transcutaneous carbon dioxide tension (TcPCO2) for assessing pressure injuries. From the results of the study we found that first, the values of TcPO2 and TcPCO2 are sensitive to the change of pressure imposed on the measured region and to the risk status of a pressure injury when a pressure is imposed. Second, the magnitude of change in TcPO2 and TcPCO2 is higher in patients with a high risk of a pressure injury compared with those who have a low risk. Third, TcPO2 and TcPCO2 are both significantly correlated with the Braden score, the widely used score for assessing the risk of a pressure injury. Therefore, TcPO2 and TcPCO2 have a potential to be an effective and convenient scientific tool for assessing the risk of pressure injuries.

Changes in alcohol use after the onset of spinal cord injury

OBJECTIVE

Identify the prevalence of alcohol consumption and binge drinking at time of spinal cord injury (SCI) onset, compare these rates to data from the general population, and identify changes in alcohol use at an average of 17 months post-injury.

DESIGN

Cross sectional, mailed self-report assessment.

SETTING

A specialty hospital in the southeastern United States.

PARTICIPANTS

Five hundred sixty-six inpatients completed the baseline measure. After eliminating those under age 18, there were 524 participants at baseline. 410 were approached for follow-up, with 201 of those responding.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Self-reported assessments were completed during inpatient rehabilitation and at follow-up approximately 17 months later. The two primary outcomes were the number of days consuming 5 or more drinks (binge drinking) and the number of days consuming any alcoholic beverages within the 30 days prior to the assessment. Comparison data were taken from the Behavioral Risk Factor Surveillance System.

RESULTS

At SCI onset, the prevalence of alcohol use, particularly binge drinking, was substantially higher than the general population (SCI = 44.9%; general population = 13%). Drinking rates decreased by 17 months post-injury.

CONCLUSION

Alcohol use and binge drinking are elevated over the general population at the time of injury. Drinking patterns reflect a decrease following injury but remain slightly elevated, signifying a need for interventions to minimize long-term health consequences.

Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study

STUDY DESIGN

Secondary analysis of data from a prospective cohort study.

OBJECTIVES

The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury.

SETTING

The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States.

METHODS

Adults with acute traumatic spinal cord injury (n=104) were recruited within 24-72 h of admission to the hospital. Pressure ulcer incidence was recorded.

RESULTS

Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1-20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3-16.63), P=0.01.

CONCLUSION

Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge

STUDY DESIGN

Prospective follow-up study.

OBJECTIVES

To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers.

SETTING

The national referral hospital in Gaborone, Botswana.

METHODS

The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics.

RESULTS

Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care.

CONCLUSIONS

Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.

Does Improvised Waterbed Reduce the Incidence of Pressure Ulcers in Patients with Spinal Injury?

Background:

Pressure ulcers are lesions caused by unrelieved pressure over bony prominences, resulting in damage to underlying tissues. The etiology is multifactorial including prolonged immobility. They usually complicate spinal cord injuries with long periods of bed confinement. The use of bed replacements markedly reduces the incidence of pressure ulcers, but the unaffordability of these replacements in low-income countries has necessitated the need to explore cheaper alternatives.

Aim and Objective:

The aim of this study was to ascertain whether the use of our cheap and locally improvised waterbeds would reduce the incidence of pressure ulcers in patients on prolonged bed confinement due to spinal injury.

Methodology:

Over a 16-month period, 51 patients (age range 1-80 years) with spinal injuries were managed conservatively in our service using improvised waterbeds in 21 (41.2%), while using the regular hospital bed/foam in 30 (58.8%). Biodata, the time interval between injury and presentation to the hospital, nature of the injury, use of improvised waterbed and development of pressure ulcer, were collected, collated, and analyzed. Statistical significance was calculated with the Chi-square test.

Results:

Most were males (98%), in the age range of 21–30 years (25.5%), and due to fall from heights (35.3%). Of 21 patients who were managed on improvised waterbeds, 6 (28.6%) had pressure ulcers, and of the 30 who did not use the waterbed, 17 (56.7%) developed ulcers. The χ² = 3.9381, while P = 0.0472. This difference was statistically significant.

Conclusion:

The improvised waterbed, which is much cheaper than the standard waterbed, was observed to have significantly reduced the incidence of pressure ulcers among our patients. Nonetheless, further studies would still be needed to confirm this observation.

Pressure ulcers in people with spinal cord injury in developing nations

STUDY DESIGN

Literature review.

OBJECTIVES

To explore the prevalence or incidence, risk factors, and costs of pressure ulcers among individuals with spinal cord injury (SCI), specifically in the context of the developing world. To highlight important targets for intervention and research for pressure ulcer management the world over.

SETTING

World Bank 'low-income' and 'middle-income' countries with a gross national income per capita <$12 746.

METHODS

PubMed search.

RESULTS

SCI-associated pressure ulcers are very prevalent in developing nations; however, reported prevalence and incidence numbers are highly variable. Risk factors for pressure ulcers are similar in developed and developing countries however many of the risk factors are more prevalent in developing nations.

CONCLUSION

SCI-associated pressure ulcers are common but can be prevented in the developing world. Key targets for interventions include acute care, nurse-to-patient ratios, support surfaces and education.

Pressure ulcers in Jordan: a snapshot survey of a tertiary public hospital

BACKGROUND

Patients are at risk of developing pressure ulcers while they are hospitalised. These risks need to be managed effectively to avoid harm and to minimise costs.

OBJECTIVE

This study was aimed at determining the prevalence and incidence of pressure ulcers at selected acute clinical settings in central Jordan.

DESIGN

A cross-sectional survey design.

METHOD

An inpatient snapshot survey was conducted over 4 weeks in the two medical wards in a tertiary public hospital.

RESULTS

190 participants were surveyed, 30 cases were identified, 53% were male, and 75% were aged 60 years or older. Prevalence was 24%, approximately half of the cases were grade 2 and 23% were grade 3 and 4. Pressure ulcers were mainly found on the sacrum (43%), followed by the heel (24%). Over 4 weeks, 29 new pressure ulcer cases were identified; 55% were male, and 90% were aged 60 years or older. Pressure ulcers were mainly-in 38% of cases-identified with cerebral vascular accident patients.

CONCLUSION

The results of the snapshot survey confirmed that there is a problem with maintaining patients' safety in terms of patients acquiring pressure ulcers in hospital. The number of pressure ulcers indicate less-than-optimal management of patient safety, which requires a more detailed investigation.

Prevalence and incidence rates of pressure ulcers in an Emergency Department

Older patients represent an increasing population in emergency department (ED) with underlying diseases and longer ED length of stay, which are potential risk factors of pressure ulcers (PUs). The aim of the study was to determine the prevalence and incidence rates of PUs in an Emergency Department and to analyse variables related to PUs occurrence. The study was carried out in the Emergency Department of Bordeaux (France), and included 602 patients from 1 to 15 June 2010. All the potential body sites of pressure were examined at admission and discharge for all the patients by trained nurses. Comorbidity score, list of treatment, length of stay (hours), PUs (including stage I) and C-reactive protein (CRP) level were systematically recorded. A total of 47 (7·8%) patients had prevalent PUs at admission and 74 (12·3%) at discharge. The cumulative incidence was 4·9% and the incidence density was 5·4 per 1000 patients per hour. In multivariate analysis, higher comorbidities (OR 1·3; P = 0·014) and CRP levels (OR 1·005; P = 0·017) were both independent risk factors for developing PU. In conclusion, these data show that even a very short stay to the ED is sufficient to induce PUs especially stage I.