A review of pressure damage prevention strategies

Reducing hospital acquired pressure ulcers in intensive care

Pressure ulcers are a definite problem in our health care system and are growing in numbers. Unfortunately, it is usually the most weak and vulnerable of our culture that faces these complications, causing the patient and their families discomfort, anguish, and economic hardship due to their expensive treatment. Data collected by the tissue viability department showed high incidence of hospital acquire pressure ulcers in the intensive care unit in March 2013. An action plan was initiated and implemented by the tissue viability team, senior nursing management, pressure ulcer prevention (PUP) team and respiratory therapists (RT's) within the ICU. Our objective was to reduce hospital acquired pressure ulcers in the intensive care unit using the plan, do, check, act quality improvement process.

Knowledge and use of pressure ulcer preventive measures in nursing homes: a comparison of Dutch and German nursing staff

AIMS AND OBJECTIVES

To examine the knowledge and use of pressure ulcer preventive measures among nursing staff in Dutch and German nursing homes.

BACKGROUND

Studies in the Netherlands and Germany have shown a large discrepancy in pressure ulcer prevalence rates among nursing homes in both countries and concluded that some of this variance could be explained by differences in pressure ulcer prevention.

DESIGN

A cross-sectional questionnaire survey nested in a prospective multicenter cohort study.

METHODS

A questionnaire was distributed to nursing staff employed in 10 Dutch nursing homes (n = 600) and 11 German nursing homes (n = 578). Data were collected in January 2009.

RESULTS

The response rate was 75·7% in the Netherlands (n = 454) and 48·4% in Germany (n = 283). Knowledge about useful pressure ulcer preventive measures was moderate in both countries, while nonuseful preventive measures were poorly known. On average, only 19·2% (the Netherlands) and 24·6% (Germany) of preventive measures were judged correctly as nonuseful. The same pattern could be seen with regard to the use of preventive measures, because nonuseful preventive measures were still commonly used according to the respondents.

CONCLUSIONS

The results indicate that the respondents' knowledge and use of pressure ulcer preventive measures could be improved in both countries, especially for nonuseful measures. Changes and improvements can be achieved by providing sufficient education and refresher courses for nurses and nursing assistants employed within Dutch and German nursing homes.

RELEVANCE TO CLINICAL PRACTICE

Recurring education about pressure ulcer prevention is required among nursing staff employed in Dutch and German nursing homes, particularly in relation to the use of ineffective and outdated preventive measures. Obstacles regarding the implementation of preventive measures should be addressed to achieve a change in practice.

Prevention and treatment of pressure ulcers in a university hospital centre: a correlational study examining nurses' knowledge and best practice

This descriptive correlational study had the goal of exploring if relationships existed between the level of knowledge of nurses concerning pressure ulcers, certain nurses' characteristics and the preventive care they applied. A multi-method approach was taken using a questionnaire to measure the level of knowledge of nurses (n = 256) and chart audits (n = 235) to identify the preventive care applied. The results show that the level of knowledge of the nurses is insufficient. They also show a correlation between a higher level of knowledge and (i) the sector of activities in which the nurses are working, (ii) the training periods provided by the university hospital centre, and a (iii) good perception by the nurses of their level of knowledge. However, training on its own cannot guarantee the provision of quality health care, as there is a wide discrepancy between what nurses know and what they put into practice.

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.

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

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.

Risk assessment scales for pressure ulcer prevention: a systematic review

AIM

This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer.

BACKGROUND

Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation.

METHOD

A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review.

FINDINGS

Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75).

CONCLUSION

There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.

Pressure ulcer prevention: nurses' knowledge, attitudes and behaviour

Despite the increased expenditure on pressure ulcer prevention strategies, incidence and prevalence is increasing. Exploring nurses' attitudes about these programmes offers an insight into why, in some cases, they are not working.

Review of Evidenced-Based Practice for the Prevention of Pressure Sores in Burn Patients

Pressure ulcers represent a complex clinical problem, with a reported incidence of 2.7% to 29.5% in hospitalized patients and an etiology that is multifactorial. The prevention of pressure sores in the burn patient population is clearly an area of practice in need of guidelines for care. A multidisciplinary group of advanced burn care professionals have compiled, critiqued, and summarized herein the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. A broad overview of risk factors and assessment scales is described, and current intervention practices and recommendations for care are provided based, whenever possible, on research findings. In addition, research questions are generated in an attempt to move the specialty of burns toward the formal investigation of pressure sores with the ultimate goal being the development of evidence-based practice guidelines.

Improvements in pain relief, handling time and pressure ulcers through internal audits of hip fracture patients

The aim of this project was to improve the outcome of hip fracture patients by optimizing preoperative pain relief, diminishing the time from admission to operation and reducing the occurrence of pressure ulcers. A retrospective study of all medical records of hip fracture patients from the last 4 months in 1998 was compared with prospective registrations during the same period in 1999 and 2000 after the introduction of quality improvements. The number of patients who waited for more than 1 hour to get pain relief was almost halved after improvements. In 1998, close to half of the patients had to wait more than 24 hours for an operation. After attention was given to quality improvements, 36% of the patients in 1999 and 34% of the patients in 2000 had to wait more than 24 hours. In addition, 18% of the patients in 1999 and 24% of the patients in 2000 vs. 11% in 1998 were operated on within 12 had to wait more than 24 hours. Pressure ulcers were considerably reduced. In total, 19% of the patients in 1998, 8% in 1999 and 4.5% in 2000 had pressure ulcers at discharge from the hospital. The outcome for hip fracture patients was improved through attention to quality improvements with all staff involved and focused on these patients.

Pressure area care: an exploration of Greek nurses' knowledge and practice

BACKGROUND

Despite a plethora of information on the prevention of pressure sores, they remain a significant problem in both hospital and community settings. The need to reduce the incidence of pressure sores has been well documented; unfortunately there is little evidence to suggest improvement. The reasons for this lack of improvement have been explored, but the picture remains unclear. While some studies have suggested that nurses have the appropriate knowledge to prevent pressure sores developing (but do not use their knowledge), others suggest that nurses' knowledge of preventive strategies is deficient. In Greece, similarly to the United Kingdom (UK), the incidence of pressure sores is high. There is currently no evidence on Greek nurses' knowledge and practice and therefore no baseline on which to build, in terms of improving practice.

AIM

The purpose of this study was to explore Greek nurses' knowledge of 'risk factors', 'areas at risk' and 'recommended preventive strategies' in relation to pressure area care. In addition, information was sought on nurses' 'current preventive practice' and any barriers to 'good practice'.

RESEARCH METHODS

The study was exploratory and descriptive, adopting a cross-sectional survey approach. The sample was drawn from the population of nurses working in a military hospital near Athens. The data were collected over a 4-week period in June 2000, using a self-completed questionnaire.

RESULTS

Although the knowledge-base of many of the nurses was good in relation to 'risk factors' and 'areas at risk', a significant proportion were unaware that methods such as 'massage' and 'donuts' are no longer recommended. This lack of knowledge influenced practice with these methods commonly being used. In relation to barriers to good practice, a significant proportion of nurses reported that they could not access, read or understand research findings. This has obvious implications for the implementation of evidence-based practice.

CONCLUSION

The results of this study suggest that the knowledge and practice of participants could be improved. It is of particular concern that methods known to be detrimental were in common use. Finally, there is a need to improve the research skills of Greek nurses in order to provide them with the appropriate knowledge to use research findings.

Influences of spatial practices on pressure ulcer management in the context of spinal cord injury

Nursing practice is significantly influenced by the type and use of space in which nursing is practised. While investigating current patterns of service delivery for the management of pressure ulcers from the perspective of people with spinal cord injuries and their families, the space in which care was delivered was identified as a central determinant of care. Qualitative methods were used to investigate consumer perspectives among patients residing in both metropolitan and rural communities who had been hospitalized for the management of pressure ulcers. Issues related to the spatial practices of the hospital are discussed, demonstrating a link between well-being and the creation of an appropriate caring milieu. It is concluded that service could be improved markedly if health-care professionals placed more consideration on the impact of space on their service delivery.

An exploration of the occurrence of pressure ulcers in a British spinal injuries unit

Spinal cord injury (SCI) is associated with increased risk of pressure ulcers, but there are few published data about this in the United Kingdom (UK). This article represents a quantitative exploration of the occurrence of pressure ulcers in a UK spinal injuries unit (SIU). The technique used is a retrospective review of records: details of 144 completed first admissions for SCI between 1998 and 2000 were entered on to a database (SPSS) for analysis. Thirty-two per cent of patients already had pressure ulcers on admission to the SIU, while a total of 56% experienced an ulcer at some stage between injury and discharge from the SIU. Four pressure ulcer risk assessment scales were used (Waterlow, Braden, Norton and SCIPUS-A). These appeared to have moderate predictive power in this population. Pressure ulcers were found to be associated with increased length of hospital stay, density of lesion, surgical stabilization of neck injury before transfer to the SIU, tracheostomy on admission to the SIU and delayed transfer to the SIU after injury. Implications for practice are discussed.

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

The purpose of the present study was to assess the prevalence of pressure ulcers and the use of Dutch guidelines for the prevention and treatment of pressure ulcers. A survey of 16,344 patients in 89 health care institutions on 1 day showed a mean prevalence of pressure ulcers of 23.1%. It was found that Dutch guidelines on some aspects of prevention and treatment of pressure ulcers were not being followed. Only 53% of the patients who should have been positioned on a support surface were positioned on such a device. Fewer than one-third of the patients who should have been repositioned, should have received nutritional support, or should have been educated received these interventions, and only 33.6% of all pressure ulcers were dressed as recommended. More attention to the dissemination and implementation of the guidelines is needed to reduce this high prevalence of pressure ulcers.

Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation

The aims were to investigate (i) registered nurses' and nursing assistants' knowledge of risk, prevention and treatment of pressure ulcer before implementing a system for risk assessment and pressure ulcer classification for patients with hip fracture (ii) interventions documented in the patient's records by registered nurses, and (iii) to what extent reported and documented interventions accord with the Swedish quality guidelines. Nursing staff (n=85) completed a questionnaire, and patient's records (n=55) were audited retrospectively. The majority of the nursing staff reported that they performed risk assessment when caring for a patient with hip fracture. These risk assessments were, however, not comprehensive. The most frequently reported preventive interventions were repositioning, use of lotion, mattresses/overlays and cushions for the heels. These interventions were to some extent documented in the patient's records. Nutritional support, reduction of shear and friction, hygiene and skin moisture, and patient's education were reported to a small extent and not documented at all. The Swedish quality guidelines regarding prevention and treatment of pressure ulcers were not fully implemented in clinical practice. It was concluded that nursing staff's knowledge and documentation of risk, prevention and treatment of pressure ulcers for patients with hip fractures could be improved.

The experience and opinions of teachers of radiography students regarding pressure ulcer prevention and management in x-ray departments

As part of a survey of pre-registration radiography course providers about pressure ulcer education, we asked respondents to comment on their personal experience of pressure ulcer prevention and management in x-ray environments, and also to identify what they consider to be important issues in this area. Responses were received from 14 out of the 24 providers of radiography education in the UK. The qualitative data was content analysed. The data suggests that radiography teachers have varied experience and a range of opinion about pressure ulcer prevention and management. The evidence supports partially anecdotal comments made to one of the authors (DJ) that radiographers cannot be expected to have knowledge of pressure ulcer prevention and management. Clinical staff with experience of pressure ulcer prevention and management should be aware of the potential risks in x-ray departments and provide support and education to radiography colleagues.

A nurse's aid to clinical selection of pressure-reducing equipment

The selection of appropriate pressure-relieving equipment for individuals in the community is an important process in the prevention of pressure ulcers. The clinical decision is made by community nurses who are accountable for their actions and who therefore have to have clear rationale for the decisions they make. Risk tools are not a completely reliable or valid method of assessing patients. The current national guidelines (National Institute for Clinical Excellence (NICE), 2001) are not specific in relation to the selection or choice of equipment. This article explores how these decisions are made.

A survey of pressure ulcer education within pre-registration radiography courses

The prevention of pressure ulcers and the management of people with pressure ulcers is multi-disciplinary, though in many places it is considered a nursing problem. Radiography environments are a potential cause of pressure ulcers. This paper describes the results of a survey of pre-registration radiography education institutions regarding the education provision on the prevention of pressure ulcers within radiography environments. The survey comprised two parts--a desk top review of course prospectuses and a postal questionnaire. Course prospectuses for 23 of the 24 institutions were examined for specific mention of prevention and management of pressure ulcers but none was found. All 24 institutions in the United Kingdom were invited to respond to a questionnaire survey, and 14 replied (58% response rate). Responses covered both diagnostic and therapeutic radiography programmes. Nine institutions specifically identify teaching on pressure ulcers, with the majority of education appearing in year 1 of the course, with some courses providing further material later in the programme. The survey confirms anecdotal evidence reported in a previous study that radiographers have little training in the prevention and management of patients at risk of developing pressure ulcers during radiographic procedures. Thirteen out of 14 institutions stated that no final year student project had considered the prevention and management of pressure ulcers in radiography environments.

An integrative review of pressure relief in surgical patients

Effective patient positioning has been an important issue throughout the history of the nursing profession. Pressure ulcers result from prolonged pressure, which causes skin, tissue, or muscle damage. Surgical patients present a unique challenge in preventing pressure ulcers because they are immobile and unable to perceive the discomfort of prolonged pressure. The purpose of this integrative review is to examine risk factors associated with pressure ulcer development in surgical patients and to examine pressure-relieving support surfaces to determine if they significantly reduce intraoperative tissue pressure and result in a lower incidence of postoperative pressure ulcers. Most of the research focuses on long-term care units, with little attention given to the acute care setting. Although the pathophysiology and etiology of pressure ulcers are well documented by years of research, the OR as an etiologic factor is largely undefined.

How effective are prevention strategies in reducing the prevalence of pressure ulcers?

The prevalence of pressure ulcers has remained constant at about 7% over the past 20 years, even though considerable time and money has been invested in various prevention strategies. This literature review explores whether pressure-prevention programmes can reduce the prevalence rate still lower or whether they are working but are limited by an increasingly aged population and rising patient acuity.

A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings

An observational study was carried out to compare wound healing on alternating-pressure mattress replacement systems (APMRS) and other surfaces in an elderly population in acute and residential care settings. Subjects were assessed for the reduction in their pressure ulcers at approximately two weeks and per day, and a visual analogue scale was used to record the patients' comfort. Seven and ten subjects were allocated to the Nimbus III APMRS (Huntleigh Healthcare Ltd) in the hospital and residential care settings respectively. There was no significant difference in the healing of the subjects' sores in the two areas either at two weeks or per day. Five people were allocated to control surfaces in the hospital setting (mainly APMRS; Pegasus Airwave, Pegasus Egerton) and ten in the residential care setting (mainly alternating-pressure overlays; AlphaXcell, Huntleigh Healthcare Ltd). There was no significant difference in the healing of subjects' sores in the two areas, either at two weeks or per day. The trial APMRS was found to be equally comfortable in either setting, and in both settings the control surfaces were not regarded as significantly different in terms of comfort. These findings, from a small sample, promote discussion about the use of pressure-relieving equipment in settings where there are older people who may be at particular risk from pressure damage and where nursing interventions are less intensive and routine.

Implementation of risk assessment and classification of pressure ulcers as quality indicators for patients with hip fractures

The aims of the study were (i) to investigate the prevalence of pressure ulcers in patients with hip fracture, on arrival at a Swedish hospital, at discharge, and two weeks post-surgery; (ii) to test whether clinical use of the Modified Norton Scale (MNS) could identify patients at risk for development of pressure ulcers; and (iii) to compare the reported prevalence of pressure ulcer in the experimental group, where risk assessment and classification of pressure ulcers was performed on a daily basis, with that of the control group, where it was not. The study design was prospective, with an experimental and a control group. The intervention in the experimental group consisted of risk assessment, risk alarm and skin observation performed by the nurse on duty, in the A & E Department, and daily throughout the hospital stay. To facilitate the nurse's assessment, a 'Pressure Ulcer Card' was developed, consisting of the MNS and descriptions of the four stages of pressure ulcers. On arrival at the hospital, approximately 20% of patients in both groups had pressure ulcers. At discharge, the rate had increased to 40% (experimental) and 36% (control). Clinical use of the MNS made it possible to identify the majority of patients at risk for development of pressure ulcers. Patients who were confused on arrival developed significantly more pressure ulcers than patients who were orientated to time and place. No significant difference was found in the reported prevalence of pressure ulcers between the experimental and control groups.

Pressure sore formation in the operating theatre: 1

While theatre nurses strive to master increasingly sophisticated equipment and techniques they must also endeavour to ensure that the quality of fundamental nursing care has positive outcomes for the patient. According to Land (1995), pressure area care is such a fundamental nursing activity that many health professionals do not recognize the importance of keeping abreast of new developments. A review of the literature concerning pressure sore formation suggests that, far from being a ward-based problem, all surgical patients experience a critical period during which they are most susceptible to pressure injury--the time spent on the operating table. This article, the first of two parts, outlines the pathophysiology of pressure sores and the contributory factors present within the operating theatre. The second part suggests nursing interventions to reduce the incidence of pressure sore formation during the perioperative phase.

[Decubitus prevention in theory and practice--a study structure with the VIPS model]

The aim of this paper is to demonstrate that the VIPS-model, a model for nursing documentation, can be used as a tool and as a structure for analyzing and categorizing literature and emprical data. The usefulness of the model is demonstrated with data from a study concerning nursing interventions to prevent decubitus.