Incidence of pressure ulcers in a neurologic intensive care unit

Potential for reducing immobility times of a mobility monitor in-bed sensor system - a stepped-wedge cluster-randomised trial

BACKGROUND

Pressure ulcer prophylaxis is a central topic in clinical care. Pressure-relieving repositioning is strongly recommended for all pressure-sensitive patients. The Mobility Monitor (MoMo) is a technical device that records a patient's movements and transmits the data to a monitor. This study investigated the extent to which the MoMo sensor system, which records and visualises patients' movements in bed, supports nurses in performing pressure-relieving repositioning in neurological and neurosurgical intensive care units (ICU).

METHODS

This stepped-wedge cluster-randomised trial involved two clusters: one neurological and one neurosurgical ICU. The study was carried out in two steps over three periods between November 2018 and May 2019, with a two-month interval between each step. At the beginning of the study, we equipped 33 beds across the two ICUs with a MoMo system. Our primary endpoint was the immobility rate, which is defined as the patient's inactive time in bed exceeding two hours without pressure-relieving movements divided by the time the MoMo was in the bed. The immobility rate ranges from 0 to below 1, with higher values indicating lower mobility. Secondary endpoints were the rate of new pressure ulcers and the rate of relevant pressure-relieving repositionings. Relevant repositionings are defined as the number of repositionings identified by the MoMo as a pressure-relieving repositioning divided by the total number of repositionings, RESULTS: 808 patients were included in the study, of whom 403 were in the control group and 405 were in the intervention group. The mean immobility rate was 0.171 during the control phase and 0.144 during the intervention phase. The estimated intervention effect was -0.0018 (95% confidence interval [-0.0471, 0.0436], p=0.94). The number of new pressure ulcers was 5/405 in the intervention phase and 15/403 in the control phase. We noted a small difference in the mean rate of relevant repositioningswith an estimated intervention effect of 0.046 (95% confidence interval [-0.018, 0.110], p=0.16).

CONCLUSION

Our results are insufficient to recommend the standardised use of mobility monitors in neurological or neurosurgical ICUs.

CLINICAL TRIAL REGISTRATION

The primary analysis was prespecified and the trial was registered in the German Clinical Trials Register (DRKS) under the reference number DRKS00015492 (31/10/2018).

Evaluation of a Pressure Injury Prevention Care Bundle in an ICU in Turkey

OBJECTIVE

To evaluate a pressure injury (PI) prevention care bundle in ICU patients diagnosed with internal diseases.

METHODS

The study had a quasi-experimental design and included 98 patients who were diagnosed with internal diseases and hospitalized in the ICU. Patients in the control group (n = 49) received routine clinical care, whereas those in the intervention group (n = 49) received the PI prevention care bundle. Data were collected using a patient information form and the Braden Scale.

RESULTS

All patients in the control group and 61.2% of the patients in the intervention group developed PIs. Those in the intervention group who developed PIs did so later on average in comparison with the control group. Patient risk of PI development increased with advanced age, low oxygen saturation, low prealbumin values, and low Braden Scale scores. Fewer PIs developed in the patients in the intervention group despite their longer duration of hospitalization and high glucose levels.

CONCLUSIONS

The PI prevention care bundle may help prevent the development of PI.

The association between obesity and pressure ulcer development in critically ill patients: A prospective cohort study

BACKGROUND

Pressure ulcers (PUs) are one of the leading potentially preventable adverse events in the hospital. Critically ill patients are at risk for the development of PUs. The primary aim of the study was to investigate the relation of PUs and obesity in critically ill ICU patients.

METHODS

A single center prospective cohort study was conducted on adult patients with obesity (defined as a body mass index BMI ≥ 30 kg/m²) and patients without obesity (BMI 18-25 kg/m²) admitted to the intensive care unit between May 2013 and July 2017 with an ICU length of stay of at least 3 days without pre-existing PUs at admission.

RESULTS

851 of 1205 patients (70.6%) had a normal BMI and 354 (29.4%) had a BMI ≥ 30 kg/m² and were considered obese. Overall, 157 patients (13.0%) developed PUs; 112/851 (13.2%) of patients without obesity and 45/354 (12.7%) of patients with obesity (p = 0.907). There was no difference in the severity (p = 0.609) and PU location (p = 0.261). Mean days to PU development was 11.1; 11.7 days for patients without obesity and 9.5 days for patients with obesity (p = 0.270). Mean days to PU recovery was 13.2, which was 14.1 days for patients without obesity and 10.8 days for patients with obesity (p = 0.215). A multivariate logistic regression model showed no significant correlation between the occurrence of PUs in the ICU and obesity (OR 0.875 with 95% CI 0.528-1.448, p = 0.594). Subgroup analysis showed that patients with morbid obesity (BMI ≥ 40 kg/m²) developed PUs earlier during ICU admission when compared to patients without obesity (p = 0.004).

CONCLUSION

Our study demonstrates that obesity is not an independent risk factor for the development of PUs in the ICU. However, patients with morbid obesity might develop PUs earlier compared to patients without obesity.

Nursing, Caregiving and Psychological support in Chronic Disorders of Consciousness: a scoping review

BACKGROUND AND AIMS

The major disorders of consciousness include Coma, Vegetative State, and Minimally Conscious State. The care and the management of patients with Disorders of Consciousness (DOC) have raised several important ethical, social and medical issues. Aim of this review is to evaluate the role of nursing and psychological support in DOC management, in order to improve the quality of life of both patients and their caregivers.

METHODS

Studies dealing with DOC, nursing and caregiving pubblished in the last 20 years (from January 2000 to June 2020) were identified by searching on PubMed, Web of Science and Cochrane databases.

RESULTS

This review highlights the important role of DOC carevigers in the complex management of these frail patients, as well as the need for a specific support and counselling of caregivers. This psychological support may be given by nurses, as they are the healthcare professionals more involved in DOC care and cure.

DISCUSSION

Over the last years, specific recommendations for the assessment and rehabilitation of patients with DOC have been promulgated by neurorehabilitation organizations to provide some guidelines for the care and cure of such frail patients. Indeed, DOC patients need a multidisciplinary approach in which both caregivers and nurses have a pivotal role.

CONCLUSIONS

As the family is a critical and fundamental aspect in the management of DOC patients, it should be considered an integral part of care in the future guidelines.

Qualitative and Quantitative Assessment of Buckwheat Husks as a Material for Use in Therapeutic Mattresses

Buckwheat husks are used in many therapeutic products such as pillows, mattresses, seats, etc. This material is proposed by producers for example for discopathy, back pain and head vasomotor disorders. Our studies evaluated the impact of using cotton mattresses with buckwheat husk fillings on people's health condition. The main research was carried out on the group of 60 people divided into 3 groups (1-people with skeletal system problems, 2-people spending a lot of time lying with the probability of pressure ulcer formation and 3-healthy people). In addition, different tests have been carried out on the possibility of colonization of mattresses by fungi, bacteria and arthropod pests, and rheological, chemical and flammability tests. The research material in the form of buckwheat husks was tested in a diverse way. All tests indicate high usefulness of husks for therapeutic activity. This material was contaminated with fungi, bacteria and pests at a very low level, related to the natural colonization of buckwheat nuts during harvest and storage. The quality of the husks was also confirmed in rheological, chemical and flammability studies. Finally, this has also been confirmed in surveys conducted on people with health problems. The analyses show that the buckwheat husk is an excellent material that can be used to fill prophylactic mattresses. This has been confirmed by the results of laboratory tests and opinions of respondents using mattresses filled with buckwheat husk.

Incidence of chronic wounds in Singapore, a multiethnic Asian country, between 2000 and 2017: a retrospective cohort study using a nationwide claims database

OBJECTIVES

Chronic wounds are common, costly and impair quality of life, yet epidemiological data are scarce. We aimed to estimate the incidence trend of a multiethnic Asian population.

DESIGN

Retrospective cohort study.

SETTING

Singapore's nationwide claims database.

PARTICIPANTS

Singaporeans and permanent residents.

OUTCOMES

Patients were identified by International Classification of Disease, Ninth Revision, Australian Modification (ICD-9-AM) and ICD-10-AM codes from all admissions between 2000 and 2017, and categorised according to aetiology: venous, arterial, diabetic and pressure. Comorbidities were extracted from a national database of Charlson Comorbidity Index scores.

RESULTS

Between 2000 and 2017, 124 023 wound-related claims among 86 631 patients were identified. Age-specific rate (ASR) and age-adjusted incidence rates of all wounds increased over 18 years, with greatest increases among those aged ≥80. In 2017, the median age of patients was 74 (IQR 63-84). Half were male (51%). 70% were ethnic Chinese, 15% Malay and 9% Indian. In 2017, the crude incidence rate (CIR) was 15 per 100 000 persons (95% CI 14 to 16) for venous wounds, 56 (95% CI 53 to 58) for arterial, 168 (95% CI 164 to 173) for diabetic and 183 (95% CI 179 to 188) for pressure wounds. The CIR of any chronic wound was 296 (95% CI 291 to 301). ASRs were greatest in patients aged ≥80: 92 (95% CI 74 to 112) for venous, 478 (95% CI 436 to 522) for arterial, 1791 (95% CI 1710 to 1876) for diabetic, 3647 (95% CI 3530 to 3766) for pressure and 4277 (95% CI 4151 to 4407) for any wound. Compared with the Chinese, Indians had thrice the ASRs of venous and arterial wounds and double the ASR of diabetic wounds. Malays had double the ASRs of arterial and diabetic wounds.

CONCLUSIONS

Chronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with ageing populations, it is crucial to address health disparities and evaluate utilisation and cost to inform clinical practice and health policy.

Incidence and risk factors associated with pressure injury in patients with traumatic brain injury

AIM

To identify the prevalence of pressure injury in patients diagnosed with traumatic brain injury and analyse the risk factors involved during hospitalization.

METHODS

This was a prospective study evaluating patients who were diagnosed with traumatic brain injury between November 2013 and September 2014. Patient characteristics, clinical and metabolic factors and therapeutic interventions, were evaluated within 30 days of hospital admission.

RESULTS

Most of the 240 patients included in the study were male, young, and non-Caucasian. The incidence of pressure injury was 18.8%. In terms of severity classification, the incidence of pressure injury was 2.7%, 23.2%, and 42.6% in mild, moderate, and severe traumatic brain injury, respectively. Pressure injury development was more likely in the first 10 days of hospitalization. A moderate or severe traumatic brain injury classification, the use of noradrenaline, and older age were pressure injury risk factors. The presence of pressure injury was associated with mortality within 30 days of hospitalization (P < .001).

CONCLUSION

The incidence of pressure injury was high in patients diagnosed with traumatic brain injury, especially in those whose injury was classified as severe. Older age, noradrenaline use, and a classification of moderate or severe traumatic brain injury were identified as pressure injury risk factors.

Skin injury prevalence and incidence in China: a multicentre investigation

OBJECTIVE:

To quantify the prevalence and incidence of different skin injuries, pressure ulcers (PU), skin tears (ST) and incontinence-associated dermatitis (IAD) in China, and to identify their causes to aid prevention and control.

METHOD:

A cross-sectional observational study was conducted across nine tertiary hospitals. Registered nurses were trained on a standard approach to injury assessment and examination. The study was carried out at the same time on the same day across the participating centres. Participating patients were examined for PU, ST or IAD.

RESULTS:

A total of 13,176 inpatients were assessed and 233 PU were identified, of which 126 occurred in hospitals, 99 cases at home and eight cases within community hospitals. In addition, there were 141 skin tears and 97 IADs.

CONCLUSION:

This study involved the largest number of hospitals, to date (in China). Therefore, the prevalence and rate of incidence of skin injury obtained in this study may represent a regional baseline in China.

Ancillary ICU Care in Patients with Acute Brain Insults

How to cite this article: Chhabra KD, Singh M. Ancillary ICU Care in Patients with Acute Brain Insults. Indian J Crit Care Med 2019;23(Suppl 2):S147–S150.

Decubitus Ulcer Development: An Investigation on Its Effect and Evidence in Home Care Patients

Background and Aims:

Decubitus ulcer (DU) is one of the commonly observed health problems among home care patients. As well as deteriorating social, physical, and psychological conditions of the patients, it is a cause of severe economic loss due to long-term bed occupancy and high care costs. This study aimed to examine the factors which affect the development of decubitus ulcer among home care patients and provide extensive data to the literature.

Patients and Methods:

This study was conducted with on home care patients aged over 40 years old who were registered at Etimesgut Ankara Sehit Sait Erturk State Hospital. Following the face-to-face interviews with the patients at home, the scores of Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), Daily Life Activities (DLA), and Geriatric Depression Scale (GDS) were recorded. Development of DU was monitored through routine examinations in the home care patients. It was encountered how SGA, MNA, DLA and GDS functioned in predicting the development of DU using logistic regression during effort and also how status of equipment and presence of comorbid diseases affected its development.

Results:

It was determined that malnutrition affected development of DU by decreasing mobility while the presence of psychological problems increased the risk for development. Furthermore, number of comorbid diseases and status of health equipment used by the patients were found effective in the development of DU.

Conclusion:

It is obvious that decreased inability of independent mobility in DLA increase the risk for malnutrition and consequently two assessments show a negative impact on psychology of the patient.

High frequency ultrasound sacral images in the critically ill: Tissue characteristics versus visual evaluation

PURPOSE

High frequency ultrasound (HFUS) systems may identify tissue injury. We compared HFUS tissue characteristics (dermal thickness and dermal density) with visual image examination.

METHODS

Longitudinal study in critically ill mechanically ventilated adults, from three ICUs (Surgical Trauma, Medical Respiratory, Neuroscience) enrolled within 24hours of airway intubation. Sacral HFUS images were obtained daily for up to seven days. Expert evaluation of the best image per day was completed and compared to HFUS generated tissue characteristics (dermal thickness and dermal density).

RESULTS

Of the113 subjects with 1614 comparisons analysed, 73.2% to 84% were normal, and 6.3% to 11.8% of the comparisons had injury present but no change was noted in the injury observed. There were no significant differences in one-day comparisons among type of injury and mean dermal thickness (p=0.6645) or dermal median intensity (adjusted p=0.06-0.17). All other day-to-day comparisons were similarly non-significant.

CONCLUSIONS

We found no association among dermal density, dermal thickness and visual examination of changes in sacral HFUS images for any day-to-day comparison. The use of sacral HFUS as a screening tool for the development of tissue injury is in its infancy. Additional comparative studies should be conducted to identify its future clinical usefulness.

Risk factors for pressure injuries among critical care patients: A systematic review

OBJECTIVE

To identify risk factors independently predictive of pressure injury (also known as pressure ulcer) development among critical-care patients.

DESIGN

We undertook a systematic review of primary research based on standardized criteria set forth by the Institute of Medicine.

DATA SOURCES

We searched the following databases: CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses Global (ProQuest), PubMed (National Library of Medicine), and Scopus. There was no language restriction.

METHOD

A research librarian coordinated the search strategy. Articles that potentially met inclusion criteria were screened by two investigators. Among the articles that met selection criteria, one investigator extracted data and a second investigator reviewed the data for accuracy. Based on a literature search, we developed a tool for assessing study quality using a combination of currently available tools and expert input. We used the method developed by Coleman et al. in 2014 to generate evidence tables and a summary narrative synthesis by domain and subdomain.

RESULTS

Of 1753 abstracts reviewed, 158 were identified as potentially eligible and 18 fulfilled eligibility criteria. Five studies were classified as high quality, two were moderate quality, nine were low quality, and two were of very low quality. Age, mobility/activity, perfusion, and vasopressor infusion emerged as important risk factors for pressure injury development, whereas results for risk categories that are theoretically important, including nutrition, and skin/pressure injury status, were mixed. Methodological limitations across studies limited the generalizability of the results, and future research is needed, particularly to evaluate risk conferred by altered nutrition and skin/pressure injury status, and to further elucidate the effects of perfusion-related variables.

CONCLUSIONS

Results underscore the importance of avoiding overinterpretation of a single study, and the importance of taking study quality into consideration when reviewing risk factors. Maximal pressure injury prevention efforts are particularly important among critical-care patients who are older, have altered mobility, experience poor perfusion, or who are receiving a vasopressor infusion.

Evaluation of external pressure to the sacral region in the lithotomy position using the noninvasive pressure distribution measurement system

BACKGROUND

Pressure ulcers (PUs) in the sacral region can be a complication of surgical procedures performed in the lithotomy position. Previous reports have noted a difference between men and women in PU development related to the supine position, and body weight and body mass index (BMI) have been also described as known risk factors in supine position-related PU development. The BIG-MAT^® system is a noninvasive pressure distribution measurement device used to measure external pressure (EP). We used this system to investigate the relationship between EP to the sacral region in the lithotomy position and selected physical characteristics.

METHODS

We recruited 21 young, healthy volunteers (11 men and 10 women, aged 21.4±0.5 years). Using the BIG-MAT system, we measured four types of EP to the sacral region: box pressure, peak box pressure, contact pressure, and peak contact pressure. We analyzed the relationships between these dynamic parameters and physical characteristics of the participants.

RESULTS

There were no differences between men and women in the four types of EP, and no significant differences related to the participants' height, weight, or BMI.

CONCLUSION

An individual's height, weight, and BMI may not contribute to the risk of inducing lithotomy position-related PUs in the sacral region. The noninvasive pressure distribution measurement system BIG-MAT for patients in the lithotomy position during surgery could become a significant device when estimating EP at the sacral region.

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit

BACKGROUND

In critically ill patients, prevention of pressure ulcers is a challenge because of the high risk for multiple comorbid conditions, immobility, hemodynamic instability, and increased use of medical devices.

OBJECTIVES

To compare the difference in incidence rates of hospital-acquired pressure ulcers (HAPUs) in critically ill patients between those treated with usual preventive care and a 5-layered soft silicone foam dressing versus a control group receiving usual care. Secondary goals were to examine risk factors for HAPUs in critically ill patients and to explicate cost savings related to prevention of pressure ulcers.

METHODS

A prospective, randomized controlled trial in the intensive care units at a 569-bed, level II trauma hospital. All 366 participants received standard pressure ulcer prevention; 184 were randomized to have a 5-layered soft silicone foam dressing applied to the sacrum (intervention group) and 182 to receive usual care (control group).

RESULTS

The incidence rate of HAPUs was significantly less in patients treated with the foam dressing than in the control group (0.7% vs 5.9%, P = .01). Time to injury survival analysis (Cox proportional hazard models) revealed the intervention group had 88% reduced risk of HAPU development (hazard ratio, 0.12 [95% CI, 0.02-0.98], P = .048).

CONCLUSION

Use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant benefit in reducing the incidence rate and severity of HAPUs in intensive care patients. This novel, cost-effective method can reduce HAPU incidence in critically ill patients.

Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study

The purpose of this study was to identify pressure ulcer (PU) incidence and risk factors that are associated with PU development in patients in two adult intensive care units (ICU) in Saudi Arabia. A prospective cohort study design was used. A total of 84 participants were screened second daily basis until discharge or death, over a consecutive 30-day period, out of which 33 participants with new PUs were identified giving a cumulative hospital-acquired PU incidence of 39·3% (33/84 participants). The incidence of medical devices-related PUs was 8·3% (7/84). Age, length of stay in the ICU, history of cardiovascular disease and kidney disease, infrequent repositioning, time of operation, emergency admission, mechanical ventilation and lower Braden Scale scores independently predicted the development of a PU. According to binary logistic regression analyses, age, longer stay in ICU and infrequent repositioning were significant predictors of all stages of PUs, while the length of stay in the ICU and infrequent repositioning were associated with the development of stages II-IV PUs. In conclusion, PU incidence rate was higher than that reported in other international studies. This indicates that urgent attention is required for PU prevention strategies in this setting.

The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital-acquired pressure ulcer patients in intensive care units

AIMS AND OBJECTIVES

To explore the quality/comprehensiveness of nursing documentation of pressure ulcers and to investigate the relationship between the nursing documentation and the incidence of pressure ulcers in four intensive care units.

BACKGROUND

Pressure ulcer prevention requires consistent assessments and documentation to decrease pressure ulcer incidence. Currently, most research is focused on devices to prevent pressure ulcers. Studies have rarely considered the relationship among pressure ulcer risk factors, incidence and nursing documentation. Thus, a study to investigate this relationship is needed to fill this information gap.

DESIGN

A retrospective, comparative, descriptive, correlational study.

METHOD

A convenience sample of 196 intensive care units patients at the selected medical centre comprised the study sample. All medical records of patients admitted to intensive care units between the time periods of September 1, 2011 through September 30, 2012 were audited. Data used in the analysis included 98 pressure ulcer patients and 98 non-pressure ulcer patients. The quality and comprehensiveness of pressure ulcer documentation were measured by the modified European Pressure Ulcer Advisory Panel Pressure Ulcers Assessment Instrument and the Comprehensiveness in Nursing Documentation instrument.

RESULT

The correlations between quality/comprehensiveness of pressure ulcer documentation and incidence of pressure ulcers were not statistically significant. Patients with pressure ulcers had longer length of stay than patients without pressure ulcers stay. There were no statistically significant differences in quality/comprehensiveness scores of pressure ulcer documentation between dayshift and nightshift.

CONCLUSION

This study revealed a lack of quality/comprehensiveness in nursing documentation of pressure ulcers. This study demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance, staging and treatment. Moreover, nursing documentation of pressure ulcers does not provide a complete picture of patients' care needs that require nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

The implication of this study involves pressure ulcer prevention and litigable risk of nursing documentation.

Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures

Background

The Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5).

Methods

The programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI).

Key findings

Pain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity.

Conclusions

The PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Iyengar Yoga Therapy Intervention for Ischial Pressure Ulcers in a Patient with Amyotrophic Lateral Sclerosis: A Case Study

BACKGROUND

Although some research suggests that the formation of pressure ulcers is rare in patients with amyotrophic lateral sclerosis (ALS), several patients have nonetheless developed this problem. To date, however, no case reports in the literature have described patients with ALS who develop ischial pressure ulcers. Outside of the ALS literature, evidence suggests that ischial pressure ulcers frequently develop in wheelchair users and also in patients treated in various health care settings.

CASE DESCRIPTION

A patient diagnosed with ALS reported the development of ischial pressure ulcers after consistent immobility for 1 year (32 months after her ALS diagnosis). This patient, who was sitting on the wounds, was treated with ointment and morphine; the latter was ineffective in controlling the pain. Moving the patient from sitting to supine, lateral, or semilateral positions, either on the bed or wheelchair, to separate the ulcers from the surface of the chair or bed was deemed impossible because of exaggeration of other symptoms, including shortness of breath and pain in other parts of the body. A new method of postural alignment was developed to alleviate the pain associated with the pressure ulcer. This method, Iyengar yoga therapy, which uses props to reposition a patient, alleviated pain and healing of two pressure ulcers of the patient after 3 weeks of starting this intervention.

CONCLUSION

Although the ischial pressure ulcers were successfully treated in a patient with ALS, further study is necessary to investigate the effectiveness of this postural alignment intervention in ALS and other patient populations for the management of ischial pressure ulcers.

A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development

The aim of this analysis was to identify the association between incontinence-associated dermatitis (IAD), its most important etiologic factors (incontinence and moisture), and pressure ulcers (PUs). A systematic review and meta-analysis were performed. We searched Medline, Embase, CINAHL, Web of Science, and the Cochrane Library for relevant papers dating through March 15, 2013. Fifty-eight studies were included. Measures of relative effect at the univariate level were meta-analyzed. In most studies (86%), a significant association between variables of interest was found, with pooled odds ratios of PUs in univariate models between 1.92 (95% CI 1.54-2.38) for urinary incontinence and 4.99 (95% CI 2.62-9.50) for double incontinence (p < .05). This evidence indicates an association between IAD, its most important etiological factors, and PUs. Methodological issues should be considered when interpreting the results of this review.

Predictive power of the Braden scale for pressure sore risk in adult critical care patients: a comprehensive review

Critical care is designed for managing the sickest patients within our healthcare system. Multiple factors associated with an increased likelihood of pressure ulcer development have been investigated in the critical care population. Nevertheless, there is a lack of consensus regarding which of these factors poses the greatest risk for pressure ulceration. While the Braden scale for pressure sore risk is the most commonly used tool for measuring pressure ulcer risk in the United States, research focusing on the cumulative Braden Scale score and subscale scores is lacking in the critical care population. This author conducted a literature review on pressure ulcer risk assessment in the critical care population, to include the predictive value of both the total score and the subscale scores. In this review, the subscales sensory perception, mobility, moisture, and friction/shear were found to be associated with an increased likelihood of pressure ulcer development; in contrast, the Activity and Nutrition subscales were not found to predict pressure ulcer development in this population. In order to more precisely quantify risk in the critically ill population, modification of the Braden scale or development of a critical care specific risk assessment tool may be indicated.

Predictive validity of the Braden scale for patients in intensive care units

BACKGROUND

Patients in intensive care units are at higher risk for development of pressure ulcers than other patients. In order to prevent pressure ulcers from developing in intensive care patients, risk for development of pressure ulcers must be assessed accurately.

OBJECTIVES

To evaluate the predictive validity of the Braden scale for assessing risk for development of pressure ulcers in intensive care patients by using 4 years of data from electronic health records. Methods Data from the electronic health records of patients admitted to intensive care units between January 1, 2007, and December 31, 2010, were extracted from the data warehouse of an academic medical center. Predictive validity was measured by using sensitivity, specificity, positive predictive value, and negative predictive value. The receiver operating characteristic curve was generated, and the area under the curve was reported.

RESULTS

A total of 7790 intensive care patients were included in the analysis. A cutoff score of 16 on the Braden scale had a sensitivity of 0.954, specificity of 0.207, positive predictive value of 0.114, and negative predictive value of 0.977. The area under the curve was 0.672 (95% CI, 0.663-0.683). The optimal cutoff for intensive care patients, determined from the receiver operating characteristic curve, was 13.

CONCLUSIONS

The Braden scale shows insufficient predictive validity and poor accuracy in discriminating intensive care patients at risk of pressure ulcers developing. The Braden scale may not sufficiently reflect characteristics of intensive care patients. Further research is needed to determine which possibly predictive factors are specific to intensive care units in order to increase the usefulness of the Braden scale for predicting pressure ulcers in intensive care patients.

Cigarette smoking and risk of pressure ulcer in adult intensive care unit patients

The objective of this study was to assess relationship between smoking, some other risk factors and ulcers development in intensive care unit. This prospective cohort study was performed in two university-affiliated hospitals. The sample consisted of adult male patients who were admitted to medical-surgical intensive care units. All eligible patients were grouped according to their cigarette smoking status as smoker and non-smoker. The final sample included 160 smokers and 192 non-smokers. Pressure ulcer occurred in 62 smoker patients and 28 of non-smoker who showed significant difference. Also number of pack-year of cigarettes smoking showed significant association with ulcer development. Ulcer stage was significantly different between the two groups. Besides of smoking, age, length of stay, faecal incontinency, diabetes mellitus, anaemia and trauma were significantly associated with pressure ulcers. Our study showed significant association between smoking and development of pressure ulcers.

Characteristics of hospitalised US veterans with nosocomial pressure ulcers

The objective of this study was to describe demographic and clinical characteristics of hospitalised US veterans with nosocomial pressure ulcer (NPU) referred to a certified Wound, Ostomy & Continence Nurse (WOCN). We conducted a retrospective review of electronic records at a Veterans Affairs Medical Center in the northwestern USA. Records of veterans with NPU referred to a WOCN (n = 29) from May 2005 to June 2006 were reviewed. Location and stage of pressure ulcer(s), Braden score on admission and when the ulcer was first noted, day of hospital stay when the ulcer was first noted, medical diagnoses and clinical conditions and events such as surgery, hypoxemia, hypoalbuminemia and hypotension were recorded. Mean age of the patients was 69·8. The most common location was the sacrum/coccyx. Most ulcers were stage 1 when identified. Braden score during admission classified half of the sample at risk, but 81% of Braden scores at ulcer occurrence were <18. Ninety percent of the sample had three or more comorbidities. Over half had died in the 1-14 months after the reviewed hospitalisation. Hospitalised veterans referred for WOCN consultation had multiple risk factors and comorbid conditions, including hypoxemia, serum albumin depletion, anaemia and hypotension. Veterans cared for in Veterans Affairs Medical Centers are known to have multiple health problems, and those in this sample not only had nosocomial pressure ulcer, but also other physiological derangements that may shorten survival.

Patient risk factors for pressure ulcer development: systematic review

OBJECTIVE

To identify risk factors independently predictive of pressure ulcer development in adult patient populations?

DESIGN

A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies.

DATA SOURCES

Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction.

REVIEW METHODS

Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken.

RESULTS

Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important.

CONCLUSIONS

Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility.

The turn team: a novel strategy for reducing pressure ulcers in the surgical intensive care unit

BACKGROUND

Pressure ulcers cause significant morbidity and mortality in the surgical intensive care unit (SICU). The purpose of this study was to determine if a dedicated team tasked with turning and repositioning all hemodynamically stable SICU patients could decrease the formation of pressure ulcers.

STUDY DESIGN

A total of 507 patients in a 20-bed SICU in a university hospital were assessed for pressure ulcers using a point prevalence strategy, between December 2008 and September 2010, before and after implementation of a team tasked with turning and repositioning all hemodynamically stable patients every 2 hours around the clock.

RESULTS

At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001). The preintervention group included 34 stage I and II ulcers and 8 higher stage ulcers. After implementation of the turn team, there were 7 stage I and II ulcers and 5 higher stage ulcers. The average Braden score was 16.5 in the preintervention group and 13.4 in the postintervention group (p = 0.04), suggesting that pressure ulcers were occurring in higher risk patients after implementation of the turn team.

CONCLUSIONS

A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention.

Análise das subescalas de Braden como indicativos de risco para úlcera por pressão

Estudo transversal com objetivo de identificar a pontuação das subescalas que avaliam o risco para úlcera por pressão na aplicação da Escala de Braden e associá-las aos motivos de internação hospitalar, às comorbidades e às características demográficas de pacientes adultos hospitalizados. A amostra constou de 187 pacientes em risco para úlcera por pressão com escore total ≤13 na referida escala. Os dados foram coletados retrospectivamente em fichas com a Escala de Braden e em prontuários, analisados pela estatística descritiva e testes de Mann-Whitney e Sperman. Os resultados demonstraram maioria de mulheres, idosos, portadores de doenças cerebrovasculares, pulmonares, cardiovasculares, metabólicas e neoplásicas. Os escores verificados pelas subescalas apontaram pacientes acamados, com mobilidade e atividade limitadas. A nutrição alterada também se mostrou fator importante, seguido pelos problemas de fricção e/ou cisalhamento e alteração da percepção sensorial e umidade. Estes achados permitiram subsidiar a qualificação da prevenção da úlcera por pressão.

Risk factors associated with pressure ulcer development in critically ill traumatic spinal cord injury patients

Critically ill spinal cord injury (SCI) patients are at high risk for pressure ulcers. Research is needed to identify risk factors for pressure ulcers. The aim of this study was to investigate risk factors and outcomes of pressure ulcers in critically ill SCI patients. This is a retrospective cohort study. Data were gathered from medical records of adult patients with SCI admitted to surgical intensive care units. Ninety-four SCI patients participated in this study. Clinical variables associated with pressure ulcers were as follows: fecal management systems, incontinence, acidosis, support surfaces, steroids, and additional equipment. Hypotension was the strongest predictor of pressure ulcers. Nursing interventions may address risk factors and improve patient outcomes.

Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: conflicting recommendations

Pressure ulcers and ventilator-associated pneumonia (VAP) are both common in acute and critical care settings and are considerable sources of morbidity, mortality, and health care costs. To prevent pressure ulcers, guidelines limit bed backrest elevation to less than 30 degrees, whereas recommendations to reduce VAP include use of backrest elevations of 30 degrees or more. Although a variety of risk factors beyond patient position have been identified for both pressure ulcers and VAP, this article will focus on summarizing the major evidence for each of these apparently conflicting positioning strategies and discuss implications for practice in managing mechanically ventilated patients with risk factors for both pressure ulcers and VAP.

Skin blood flow response to 2-hour repositioning in long-term care residents: a pilot study

PURPOSE

The purpose of this noninvasive pilot study was to examine the changes in transcutaneous oxygen (tcO2), skin temperature, and hyperemic response in the heels, sacrum, and trochanters in a 2-hour loading-unloading condition in nursing home residents who are positioned in supine and lateral positions.

DESIGN

A 1-group, prospective, repeated-measures design was used.

SUBJECTS AND SETTING

Nine subjects (5 males, 4 females) with a mean age of 85.3 ± 10.86 years (mean ± SD) who required help in turning and positioning at a skilled nursing facility participated in the study.

METHODS

Oxygen and temperature sensors were placed on the heels, trochanters, and sacrum. The subject was (1) positioned lateral for 30 minutes (preload); (2) turned to the supine position with head of the bed at 30° for 2 hours (both sacrum and heels were on the bed surface) (loading); and (3) positioned lateral for 2 hours (unloading). Subjects were turned to either the right or the left side.

RESULTS

Friedman test showed no statistical differences in tcO₂ or skin temperature on the sacrum, heels, or trochanters during preload, supine, and lateral positioning (P > .5). Individual data revealed that hyperemic response was seen in 6 of the 9 subjects when the position was changed from supine to lateral. Only one-third of the subjects attained a sacral tcO₂ of 40 mm Hg or more at the end of the 2-hour lateral positioning. tcO₂ on both heels decreased within the first 30 minutes of loading.

CONCLUSION

Two hours of staying in the supine position lowered sacral oxygenation to less than 40 mm Hg, in some subjects, regardless of whether there was adequate tcO₂ at preload. Repositioning to a lateral position after 2 hours of placement in a supine position did not cause the tcO₂ to return to preload level. The efficacy of a 2-hour repositioning schedule requires further investigation. Since heel tcO₂ was reduced after 30 minutes of loading, further work is needed to determine whether the heels should be offloaded with more frequent repositioning.

Implantação da Escala de Braden em uma unidade de terapia intensiva de um hospital universitário

Estudo prospectivo, longitudinal, que teve por objetivos implantar a Escala de Braden (EB) como instrumento de predição de risco para úlcera por pressão (UP) e analisar os resultados do seu uso em uma unidade de terapia intensiva. A amostra foi de 74 pacientes, os dados coletados por instrumento contendo a EB, analisados pela estatística descritiva simples. Encontrou-se 58 (78,37%) pacientes com escore < a 13 e uma incidência de UP de 25,67%. Em 45 (60,8%) pacientes houve o preenchimento diário da EB, destes 5 (11,1%) desenvolveram UP; em 29 (39,1%) não houve aplicação diária da EB, destes, 14 (48,2%) desenvolveram UP. Verificou-se aplicabilidade da EB, o que possibilitou identificar os pacientes em risco para UP. As dificuldades na implantação da EB foram referentes à periodicidade de seu preenchimento, que aponta à necessidade da conscientização e preparo dos enfermeiros para o uso desta ferramenta no cuidado ao paciente.

Predictors of pressure ulcers in adult critical care patients

BACKGROUND

Pressure ulcers are one of the most underrated conditions in critically ill patients. Despite the introduction of clinical practice guidelines and advances in medical technology, the prevalence of pressure ulcers in hospitalized patients continues to escalate. Currently, consensus is lacking on the most important risk factors for pressure ulcers in critically ill patients, and no risk assessment scale exclusively for pressure ulcers in these patients is available.

OBJECTIVE

To determine which risk factors are most predictive of pressure ulcers in adult critical care patients. Risk factors investigated included total score on the Braden Scale, mobility, activity, sensory perception, moisture, friction/shear, nutrition, age, blood pressure, length of stay in the intensive care unit, score on the Acute Physiology and Chronic Health Evaluation II, vasopressor administration, and comorbid conditions.

METHODS

A retrospective, correlational design was used to examine 347 patients admitted to a medical-surgical intensive care unit from October 2008 through May 2009.

RESULTS

According to direct logistic regression analyses, age, length of stay, mobility, friction/shear, norepinephrine infusion, and cardiovascular disease explained a major part of the variance in pressure ulcers.

CONCLUSION

Current risk assessment scales for development of pressure ulcers may not include risk factors common in critically ill adults. Development of a risk assessment model for pressure ulcers in these patients is warranted and could be the foundation for development of a risk assessment tool.

Predictive validity of the Braden scale for pressure ulcer risk in critical care patients

This methodological study aimed to evaluate the predictive validity of the Braden scale in critical care patients. The study was conducted in four intensive care units of a general private hospital. After approval of the project by the Hospital Ethics Committee, during six months, adult patients admitted to ICUs with a Braden score <18 and without PU were assessed upon admission and at 48-hours intervals as long as the patient remained at risk or until the development of PU, patients' discharge, death or transfer from the ICU. The cut-off scores of the Braden scale in the first, second and third assessments were 12, 13 and 13, respectively. Sensitivity was 85.7%, 71.4% and 71.4% and specificity was 64.6%, 81.5% and 83.1%, respectively. Areas under the ROC curves revealed very good accuracy for the cut-off scores. The Braden cut-off score 13 in the third assessment showed the best predictive performance in critical care patients.

Estado nutricional e capacidade funcional na úlcera por pressão em pacientes hospitalizados

OBJETIVO: Correlacionar a incidência de úlcera por pressão com o estado nutricional e a capacidade funcional de pacientes internados. MÉTODOS: Estudo de corte transversal realizado em dois hospitais, totalizando 130 pacientes (idade mediana = 52 (14-85) anos, 77 (59,2%) homens e 53 (40,8%) mulheres), sendo 72 (55,4%) internados para tratamento clínico, 40 (30,8%) para tratamento cirúrgico e 18 (13,8%) em terapia intensiva. Os pacientes foram avaliados pela avaliação subjetiva global e classificados, de acordo com sua capacidade funcional, em acamados e não acamados. Registrou-se a presença e número de úlceras, e sua gravidade. A classificação das úlceras foi estabelecida como grave, para lesões de 3º e 4º graus, e leve, para os graus 1 e 2. RESULTADOS: A incidência de úlcera por pressão na população estudada foi de 19,2% (n=25). Não houve associação significativa com o sexo, a idade e tipo de tratamento do paciente. Os pacientes acamados apresentaram 7,5 vezes mais chance de apresentar úlceras (19/50; 38,0%) do que os que deambulavam (6/80; 7,5%; OR=7,5; IC95%: 2,7-20,7; p<0,001). A incidência de úlcera nos pacientes gravemente desnutridos (20/49; 40,8%) foi 10 vezes maior que nos pacientes considerados não gravemente desnutridos (5/81; 6,1%; OR=10,4 IC95%: 3,6-30,5; p<0,0001) Pela análise multivariada, tanto a capacidade funcional (acamado, OR=9,2; IC95%: 2,8-30,1; p<0,001) quanto o estado nutricional (desnutrido grave, OR=3,8; IC95%: 1,0-13,9; p=0,04) associaram-se com a úlcera por pressão. CONCLUSÃO: A incidência de úlcera por pressão está diretamente correlacionada com a desnutrição e com a restrição ao leito dos pacientes internados.

Factors associated with pressure ulcers in patients in a surgical intensive care unit

PURPOSE

We sought to describe the occurrence of pressure ulcers in patients managed in a surgical intensive care unit (ICU) and report preliminary work toward development of a pressure ulcer risk assessment tool for use in this population that incorporates comorbidities and other factors not addressed in previous instruments.

SUBJECTS AND SETTINGS

Three hundred sixty-nine patients managed in the surgical ICU at Yale-New Haven Hospital comprised the sample.

METHODS

Demographic and clinical data, including Braden Scale scores, were collected in this prospective, 2-phase study. The principal investigator (G.C.S.) performed skin assessments on all patients. We used chi-square analysis and t tests to determine variables to include in a stepwise logistic regression analysis to determine factors independently associated with the development of pressure ulcers.

INSTRUMENT

We collected data, using a form we developed that contained demographic and clinical factors found in previous research and in our clinical practice to be associated with pressure ulcers.

RESULTS

Eighty-eight out of 369 patients (23.9%) experienced a hospital-acquired pressure ulcer. Braden Scale scores ranged from 6 to 21, with a mean score of 11.9 ± 2.2. A lower Braden Scale score, the presence of diabetes mellitus, and patient age 70 years or older independently predicted the development of a pressure ulcer. These factors have been incorporated into the preliminary Surgical ICU Pressure Ulcer Risk Assessment scale.

CONCLUSIONS

Findings from this study suggest that, in addition to a low Braden Scale score, age >70 years and a diagnosis of diabetes may represent clinically relevant pressure ulcer risk factors in the surgical intensive care population and that patients with these factors may benefit from more aggressive preventive care. In addition, the Surgical ICU Pressure Ulcer Risk Assessment scale requires additional psychometric testing before its use can be recommended for the research or practice settings.

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

STUDY DESIGN

Pressure ulceration and other complications constitute an encumbrance in the management of spinal cord injury in many services with limited resources in developing countries. These services undertake patients' care without adequate prehospital care, limited modern infrastructure and limited number of trained staff.

OBJECTIVES

To evaluate the associated risk factors for pressure ulceration in traumatic spinal cord injured managed in a resource constrained spinal injury unit in Lagos, Nigeria. A regional acute trauma and rehabilitation centre serving a population of >20 million.

METHODS

This is a prospective study in patients presenting with traumatic spinal cord injury between 1 October 2004 and 30 November 2006. The data collected include demographic characteristics, interval before admission in the unit, type of spinal cord injury and serum albumin. The incidence of pressure ulcers and the isolated organisms was recorded for patients who developed pressure ulcers on admission and during the period of stay in the unit. The length of hospital stay was also recorded for all the patients.

RESULTS

The overall incidence of pressure ulceration on admission was 57.1%. There was an average lengthening of hospital stay of 33.1 days in the group of patients with pressure ulceration compared to patients without pressure ulcers. The nutritional status on admission, interval before admission and the type of neurological injury were significant factors for the incidence of pressure ulcers.

CONCLUSION

The incidence of pressure ulceration was high, delay in admission and poor nutritional status may be significant factors in the incidence of pressure ulceration in spinal cord injury.

Use of mobility subscale for risk assessment of pressure ulcer incidence and preventive interventions: A systematic review

BACKGROUND

Pressure ulcers remain a serious problem for patients and providers in healthcare. When a pressure ulcer develops, it can inflict pain and cause untoward complications such as severe infections, surgery, prolonged hospital stay and even death.

OBJECTIVE

The objective of this review was to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden pressure ulcer risk assessment scale. However, due to lack of research studies, the focus of this review was extended to include the use of other assessment tools for hospital acquired pressure ulcer risk.

INCLUSION CRITERIA

Quantitative studies that reported data on mobility and pressure ulcer development or preventive interventions, irrespective of their design were included in the review.The review focused on adult patients admitted to an acute care facility, who underwent a pressure ulcer risk assessment, and had no pressure ulcers on admission.This review considered studies that use Braden mobility subscale assessmentThis review compared the use of full Braden risk assessment scale where available only when it was included within the same study,This review considered: SEARCH STRATEGY: A search for published and unpublished studies from 2000 to 2010 of major healthcare related electronic databases was conducted. Studies in other languages that were translated into English were included in the review.

ASSESSMENT OF QUALITY

The papers that were selected for possible inclusion were assessed by two independent reviewers for methodological validity using standardised critical appraisal instruments from the Joanna Briggs Institute.

DATA COLLECTION AND ANALYSIS

Data from included studies were extracted and analysed using Revman5 software.

RESULTS AND CONCLUSIONS

Eighteen studies were included in this review. The findings suggest that the risk of pressure ulcer development was higher when the patient was identified as having impaired mobility, as assessed using the Braden subscale mobility or other similar mobility scales. However, there is little conclusive evidence to indicate that using mobility assessment alone is comparable to using Braden or other risk assessment scales in reducing the incidence of pressure ulcer. Evidence for association between assessment of mobility and endorsement of preventive interventions was significant. However, this finding was based on only one study. No evidence found on the reliability of mobility assessment as a tool to predict pressure ulcer risk. Nor was there evidence on the frequency of assessment using the mobility assessment tool.

IMPLICATIONS FOR PRACTICE

Assessment of mobility may be a useful measure in an acute care setting in relation to assessing the risk of developing pressure ulcer. However, there is not enough evidence to conclude that mobility assessment alone can replace the more common risk assessment scales such as Braden scale in predicting incidence of pressure ulcer.

IMPLICATIONS FOR RESEARCH

Further research is required to.