Intervention studies to reduce the prevalence and incidence of pressure sores: a literature review

Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions

BACKGROUND

A systematic review of the literature on nurse-focused interventions conducted in the hospital setting informs the evidence base for implementation of pressure ulcer (PU) prevention programs. Despite the availability of published guidelines, there is little evidence about which interventions can be successfully integrated into routine care through quality improvement (QI). The two previous literature syntheses on PU prevention have included articles from multiple settings but have not focused specifically on QI.

METHODS

A search of six electronic databases for publications from January 1990 to September 2009 was conducted. Trial registries and bibliographies of retrieved studies and reviews, and Internet sites of funding agencies were also searched. Using standardized forms, two independent reviewers screened publications for eligibility into the sample; data were abstracted and study quality was assessed for those that passed screening.

FINDINGS

Thirty-nine studies met the inclusion criteria. Most of them used a before-and-after study design in a single site. Intervention strategies included PU-specific changes in combination with educational and/or QI strategies. Most studies reported patient outcome measures, while fewer reported nursing process of care measures. For nearly all the studies, the authors concluded that the intervention had a positive effect. The pooled risk difference for developing PUs was -.07 (95% confidence interval [CI]: -0.0976, -0.0418) comparing the pre- and postintervention status.

CONCLUSION

Future research can build the evidence base for implementation through an increased emphasis on understanding the mechanisms by which improved outcomes are achieved and describing the conditions under which specific intervention strategies are likely to succeed or fail.

Do pressure ulcer risk assessment scales improve clinical practice?

Standardized assessment instruments are deemed important for estimating pressure ulcer risk. Today, more than 40 so-called pressure ulcer risk assessment scales are available but still there is an ongoing debate about their usefulness. From a measurement point of view pressure ulcer (PU) risk assessment scales have serious limitations. Empirical evidence supporting the validity of PU risk assessment scale scores is weak and obtained scores contain varying amounts of measurement error. The concept of pressure ulcer risk is strongly related to the general health status and severity of illness. A clinical impact due do the application of these scales could also not be demonstrated. It is questionable whether completion of standardized pressure ulcer risk scales in clinical practice is really needed.

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

AIMS

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

BACKGROUND

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

DESIGN

The study was conducted as a descriptive and prospective study.

METHOD

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

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.

Pressure ulcer prevention and management strategies in Turkey

Pressure ulcers are a serious problem that can lead to pain and delayed recovery. In Turkey, the selection of dressing products is usually left to the nurse managing the patient and depends on several factors, including the condition of the wound, the nurse's knowledge, and the nurse's experience. The aim of this study was to determine prevention and management strategies for pressure ulcer care in hospitalized patients in Turkey and to identify the factors that influence the selection of products by nurses. The descriptive study was carried out in various departments (orthopedic, neurological, oncology, and intensive care) where bedridden patients were found. A total of 110 nurses volunteered to participate. Data were collected by means of a questionnaire developed after a review of the literature. Only 32% of the nurses made use of a pressure ulcer care risk evaluation scale (Norton scale), and air mattresses were used by 89% as a preventive measure with patients who were at risk. When pressure ulcers occurred, advanced wound care products were preferred by most of the nurses. Seventy four percent of nurses considered the condition of wound for selection of products. Despite correctly noting several strategies for prevention of pressure ulcers, 9% of nurses also described massage around boney prominence and the use of inflatable rings as effective preventive strategies. This descriptive study shows that nurses in Turkey are primarily responsible for prevention and management of pressure ulcer care and that both traditional dressing products and advanced wound care products are used in the care of all stages of pressure ulcers in Turkey. It also illustrates the need for ongoing pressure ulcer education to promote evidence-based practice and reduce the use of ineffective (or harmful) strategies.

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.

Prevalence, incidence and predictors of pressure ulcers in a tertiary hospital in Singapore

OBJECTIVE

In 2002 the hospital under study implemented a pressure ulcer standard care plan. This follow-up study aimed to determine the prevalence and incidence of pressure ulcers, whether demographic characteristics and medical diagnosis differed between those individuals who did and those who did not develop ulcers and the predictors of pressure-ulcer formation.

METHOD

The prevalence study used a cross-sectional design, while the incidence study was a prospective cohort study. Participants were scored using the Braden scale and were examined for the presence of pressure ulcers. Those who were ulcer free were monitored twice weekly until they were discharged or for 28 days.

RESULTS

The prevalence of pressure ulcers was 18.1% (95% CI: 15.5-20.9%), while the incidence was 8.1% (95% CI: 6.1-10.4%). Participants with ulcers were older, had a longer mean length of hospital stay, lower Braden scores and were diagnosed with or had a history of cardiovascular diseases or sepsis. Logistic regression found that the total Braden score was the only significant predictor of pressure ulcers. Compared with scores 16-23, the odds ratios were 7.7 (95% CI: 3.5-17.1, p < 0.001) and 12.5 (95% CI: 4.5-34.6, p < 0.001) for scores 12-15 and 6-11 respectively. Demographic characteristics, diagnosis and length of hospital stay were not significant predictors.

CONCLUSION

The study identified a modest decrease in incidence and improvements in nursing care following the implementation of the care plan. It suggests that Braden scores are predictive of those at-risk of developing pressure ulcers.

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 advances in pressure ulcer management since 1992

This article seeks to review the progress in the treatment and prevention of pressure ulcers over the last 10 years under the headings of attitudes, politics, research and best practice. It is considered that attitudes have changed and there is a greater awareness of, and interest in, the topic among other healthcare professionals, not just nurses. This may be in part because the topic has risen up the political agenda following studies that have highlighted the numbers of sufferers and the cost of treatment. Unfortunately, there is a scarcity of high quality research to inform practice. Despite these limitations, overall, there has been some progress in preventing and treating pressure ulcers, but there is still a considerable journey ahead.

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

BACKGROUND

In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study.

AIM

Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee].

METHOD

A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions.

RESULTS

Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities.

CONCLUSION

It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.

How can we improve prevalence and incidence monitoring?

Many studies have attempted to calculate pressure ulcer occurrence rates, but their results cannot be compared due to variations in the methodologies used. How can this problem be overcome?

Examining the validity of pressure ulcer risk assessment scales: developing and using illustrated patient simulations to collect the data

Simulations are of particular advantage in research studies where large samples are necessary to achieve statistical power and the information must be collected under uniform conditions in order to aid interpretation. In the study reported below, simulation was achieved through the use of medical photography accompanied by case studies of the same patients. All information was collected on the same day. The purpose of the study was to determine the validity of the three pressure ulcer risk assessment scales most commonly used in clinical nursing practice in the UK. Each clinical nurse assessed the same four patients using three risk assessment scales and a visual analogue scale designed to capture their own clinical judgement. External validity was assessed by a panel of tissue viability experts who provided independent ratings. Data were obtained from 236 clinical nurses, yielding 941 risk assessments. Experience with this approach to data collection suggests that it requires careful planning. This should include measures to ensure that the simulated information is valid and that all data collectors have been adequately trained and are able to motivate the nurses participating in the study. Providing consideration is given to these issues, the use of simulation can help to collect data that would be difficult to obtain by more conventional means. It is also important to recognize that clinical decisions are de-contextualized in simulations because they are reduced to verbal and visual summaries. The decision to use simulations should thus be taken only if this is acknowledged.