The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence

A feedback system to improve the quality of nutritional care

OBJECTIVE

The main objective of this study was to develop a feedback system that improves the translation of malnutrition performance data from the Dutch National Prevalence Measurement of Care Problems (LPZ) into relevant evidence- and practice-based interventions in care homes.

METHODS

The process consisted of two stages. The first was the development of a feedback system. Twenty-four interviews were held with health care professionals in care homes that participated in the LPZ to gain insight into needs regarding the translation of performance data into relevant improvement interventions. Subsequently, three multidisciplinary focus groups discussed how to develop a feedback system to deal with those needs. In the second stage, the feasibility of this system was evaluated via a questionnaire (N = 93) that was sent to care homes participating in LPZ.

RESULTS

It was important that performance data be more transparent regarding which information was relevant and that insight was gained into how to improve nutritional care. To address these needs, a dashboard was developed to present performance data in a transparent way. Subsequently, a decision tree was developed that links LPZ dashboard outcomes to evidence-based nutritional interventions for care homes. Forty-seven respondents (50.5%) evaluated the new feedback system (the dashboard and the decision tree) as feasible. The content and design were perceived to be very useful. Half of the participating institutions had already started working with improvement activities.

CONCLUSION

The developed feedback system was evaluated as useful for improving nutritional patient care in the future. This system will also be developed for other health care settings.

The prevalence of pressure ulcers in four paediatric institutions

AIM AND OBJECTIVE

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

DESIGN

A point prevalence study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Decreasing trends in malnutrition prevalence rates explained by regular audits and feedback

To our knowledge, no studies have analyzed the influence of annual audit and feedback on the prevalence rates of malnutrition. This study analyzes the trend of malnutrition prevalence rates between 2004 and 2007 and the effects of previous audits and feedback from the annual Dutch National Prevalence Measurement of Care Problems (LPZ) and the effect of the participation in Dutch national improvement programs. From 2004 to 2007, an annual multicenter study was performed in Dutch hospitals, nursing homes, and home care organizations using a standardized questionnaire involving measurements at institutional, ward, and patient levels. The data were analyzed by logistic multilevel analysis. Nutritional status was assessed by BMI, undesired weight loss, and nutritional intake. In total, 80 hospitals, 141 nursing homes, and 48 home care organizations participated. The prevalence of malnutrition tended to decrease in hospitals and home care over the years. In nursing homes, prevalence rates were stable. Furthermore, the more often hospitals and home care organizations participated in the annual LPZ audits, the lower the prevalence rate of malnutrition (P < 0.001). Participation in national improvement programs also resulted in lower prevalence rates (P = 0.027). In conclusion, malnutrition prevalence rates have decreased over the last 4 y in hospitals and home care in The Netherlands. Participation in the LPZ and involvement in national improvement programs positively influenced these malnutrition prevalence rates, possibly indicating that increasing awareness and actively working toward improvement could be important in lowering these rates.

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.

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

AIMS AND OBJECTIVES

To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention.

BACKGROUND

Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care.

METHODS

A cross-sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence.

RESULTS

There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6.8%. The age-, sex- and risk-standardized prevalence per regional department varied between 4.9% and 9.1%. Of the 744 subjects at risk, 33 (4.4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64.8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30.8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4.8% adherence, 76.6% no adherence and 18.6% no prevention. A proportion of 22.2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21.4% of all risk cases.

CONCLUSIONS

The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. RELEVANCE TO THE CLINICAL PRACTICE: The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improving pressure ulcer prevention in a nursing home: action research

A study conducted in Sunderland investigated how staff in a private sector care home manage pressure ulcer prevention and what staff perceive to be the reasons why residents in their care develop pressure ulcers. It also identified how using a collaborative action research study design (utilizing an action research cycle with collaborative focus groups) can bring about an improvement in practice, by allowing the staff to reflect on and analyse the way they work and develop and implement strategies to provide solutions to the problems they identify.

Skin Care Intervention for Patients Having Cardiac Surgery

• Background Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients.

• Objectives To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers.

• Methods A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown.

• Results Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = &lt;.001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery.

• Conclusions Skin assessments and nursing interventions should be increased on the day of surgery and the first to fifth postoperative days, including multiple assessments and skin care focused on maintaining skin integrity.