EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators

Medical device related pressure ulcers in Jordan: Prevalence study among critically ill patients

Background

Medical device‐related pressure ulcers are increasingly common in critical care units. These ulcers can be complicated due to the necessity of the device for diagnosis or treatment.

Purpose

To determine the prevalence of and risk for medical device‐related pressure ulcers in critical care units in Jordan in addition to identifying the preventive measures for those ulcers as well as identifying the most frequently used medical devices that cause ulcers and to assess the relationships between prevention measures and developing ulcers.

Methods

A cross‐sectional survey was used to assess ulcers among 318 patients who were elder than 18 years old. Data collection was based on an outline published by the European Pressure Ulcer Advisory Panel, Braden Scale, and an author‐developed specific checklist.

Results

The prevalence rate of medical device‐related pressure ulcers was 38.1%. Most affected sites were sacrum and heel, and most affected were those with old age, being admitted to public hospitals, and with a prolonged hospital stay. About half of the patients (46.3%) had severe risk. Only 17% of the patients who were at risk got adequate preventive measures. Face masks, endotracheal tubes, pulse oximetry probes, and intravenous catheters were associated with almost half of the ulcers.

Conclusion

Medical device‐related pressure ulcers are threats to patient safety and quality of nursing care in hospitals, which require determining appropriate preventive measures. Key messages:

Medical device‐related pressure ulcers are common among patients in critical care units, which raise the need to evaluate the prevalence of such type of ulcers in those patients.

Three hundred and eighteen patients were investigated for the prevalence of medical device‐related pressure ulcers through a cross‐sectional survey.

Patients in critical care units in Jordan had a high prevalence rate for medical device‐related pressure ulcers, which require the need to apply appropriate preventive measures.

The prevalence of pressure ulcers in Europe, what does the European data tell us: a systematic review

OBJECTIVE

The main aim of this systematic review was to establish the prevalence of pressure ulcers (PU) within published studies from Europe.

METHOD

Using systematic review methodology, quantitative design studies which explored prevalence data and/or the epidemiology of PUs in Europe were considered. The primary outcome was PU prevalence. The search, conducted in April 2019, using Cochrane, Medline, Embase, CINAHL, PubMed, Scopus and Web of Science databases, returned 3065 records, of which 79 met the inclusion criteria. Data were extracted using a pre-designed extraction tool, and validity analysis was undertaken using the Evidence-Based Librarianship (EBL) Critical Appraisal Checklist.

RESULTS

We included 79 articles in this review. Across the studies, the median prevalence was 10.8% (standard deviation: 7%; range: 4.6-27.2%). The highest PU prevalence reported was from the Netherlands (27.2%; n=17,494 participants), and the lowest was reported from Finland (4.6%; n=629 participants). Almost 32.4% (n=151,195) of the PUs were category I and the most common site for PUs was the sacrum.

CONCLUSION

The prevalence data is consistently high. These data indicate the continued need for further resource allocation into PU prevention and management.

Effects of ambient conditions on the risk of pressure injuries in bedridden patients-multi-physics modelling of microclimate

Scientific evidence regarding microclimate and its effects on the risk of pressure ulcers (PU) remains sparse. It is known that elevated skin temperatures and moisture may affect metabolic demand as well as the mechanical behaviour of the tissue. In this study, we incorporated these microclimate factors into a novel, 3-dimensional multi-physics coupled model of the human buttocks, which simultaneously determines the biothermal and biomechanical behaviours of the buttocks in supine lying on different support surfaces. We compared 3 simulated thermally controlled mattresses with 2 reference foam mattresses. A tissue damage score was numerically calculated in a relevant volume of the model, and the cooling effect of each 1°C decrease of tissue temperature was deduced. Damage scores of tissues were substantially lower for the non-foam mattresses compared with the foams. The percentage tissue volume at risk within the volume of interest was found to grow exponentially as the average tissue temperature increased. The resultant average sacral skin temperature was concluded to be a good predictor for an increased risk of PU/injuries. Each 1°C increase contributes approximately 14 times as much to the risk with respect to an increase of 1 mmHg of pressure. These findings highlight the advantages of using thermally controlled support surfaces as well as the need to further assess the potential damage that may be caused by uncontrolled microclimate conditions on inadequate support surfaces in at-risk patients.

Inter-rater reliability of the Reaper Oral Mucosa Pressure Injury Scale (ROMPIS): A novel scale for the assessment of the severity of pressure injuries to the mouth and oral mucosa

BACKGROUND

Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth.

OBJECTIVES

This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa.

METHODS

The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha (α).

RESULTS

Among ICU nurses (n=52), IRR of the ROMPIS was α=0.307; improving to α=0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care (n=8), IRR was α=0.306; or α=0.443 excluding responses indicating that wounds were unstageable.

CONCLUSIONS

An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.

Pressure Ulcers Prevalence in the Acute Care Setting: A Systematic Review, 2000-2015

Little is known about the prevalence of pressure ulcer (PrU) in acute care settings. The aim of this study is to determine the prevalence rate of PrU in acute care settings and to assess the methodological quality of the reviewed publications. The Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, MEDLINE, and Cochrane Database of Systematic Reviews were searched using the keywords pressure ulcer or decubitus ulcer or bed sore or pressure sore or pressure injury, with prevalence and acute care, for studies published between January 2000 and December 2015. Nineteen publications met our criteria. These reported a prevalence range of between 7.8% and 54% for those using European Pressure Ulcer Advisory Panel methodology, 6% and 22% for those using National Pressure Ulcer Advisory Panel methodology, and 4.94% for the study that employed the Torrance system. The likely worldwide PrU prevalence rate range in acute care settings is between 6% and 18.5%. Prevalence rate varies between studies depending on the methodology of data collection. Moreover, the methodological quality of the included studies in the review was variable; therefore, it was difficult to compare the prevalence rate between the studies, settings, and countries.

Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis

OBJECTIVE

To systematically review studies reporting the prevalence in general adult inpatient populations of foot disease disorders (foot wounds, foot infections, collective 'foot disease') and risk factors (peripheral arterial disease (PAD), peripheral neuropathy (PN), foot deformity).

METHODS

A systematic review of studies published between 1980 and 2013 was undertaken using electronic databases (MEDLINE, EMBASE and CINAHL). Keywords and synonyms relating to prevalence, inpatients, foot disease disorders and risk factors were used. Studies reporting foot disease or risk factor prevalence data in general inpatient populations were included. Included study's reference lists and citations were searched and experts consulted to identify additional relevant studies. 2 authors, blinded to each other, assessed the methodological quality of included studies. Applicable data were extracted by 1 author and checked by a second author. Prevalence proportions and SEs were calculated for all included studies. Pooled prevalence estimates were calculated using random-effects models where 3 eligible studies were available.

RESULTS

Of the 4972 studies initially identified, 78 studies reporting 84 different cohorts (total 60 231 517 participants) were included. Foot disease prevalence included: foot wounds 0.01-13.5% (70 cohorts), foot infections 0.05-6.4% (7 cohorts), collective foot disease 0.2-11.9% (12 cohorts). Risk factor prevalence included: PAD 0.01-36.0% (10 cohorts), PN 0.003-2.8% (6 cohorts), foot deformity was not reported. Pooled prevalence estimates were only able to be calculated for pressure ulcer-related foot wounds 4.6% (95% CI 3.7% to 5.4%)), diabetes-related foot wounds 2.4% (1.5% to 3.4%), diabetes-related foot infections 3.4% (0.2% to 6.5%), diabetes-related foot disease 4.7% (0.3% to 9.2%). Heterogeneity was high in all pooled estimates (I(2)=94.2-97.8%, p<0.001).

CONCLUSIONS

This review found high heterogeneity, yet suggests foot disease was present in 1 in every 20 inpatients and a major risk factor in 1 in 3 inpatients. These findings are likely an underestimate and more robust studies are required to provide more precise estimates.

Electronic versus paper records: documentation of pressure ulcer data

BACKGROUND

The documentation of patient data on health records is a vital component of the care process. Accurate and complete recording of this data is a necessary practice. The adoption of electronic health records to improve the quality of nursing documentation is on the rise.

OBJECTIVES

This study compares the accuracy and completeness of pressure ulcer data documentation between electronic and paper records.

DESIGN

A descriptive, comparative design with a retrospective review of patient records. Settings and sample: Two hospitals were chosen purposefully, one using electronic recording of patient data and the other using paper records.

METHODS

In the first phase, all hospitalised patients aged 18 years and over were inspected for pressure ulcers. In the second phase, the files of patients with pressure ulcers were audited.

RESULTS

Of the 52 patients with ulcers found in the hospital that used an electronic system, 43 of their records documented the pressure ulcers (83%). Of the 55 patients with pressure ulcers in the hospital using paper records, 39 files had corresponding documentation of the presence of a pressure ulcer (71%).

CONCLUSION

In terms of accuracy and completeness, more comprehensive documentation practice was found on the electronic health records compared with paper records. However, both types of systems have shortcomings in the practice of pressure ulcer data documentation.

Pressure ulcer prevalence, use of preventive measures, and mortality risk in an acute care population: a quality improvement project

The primary aim of this quality improvement project was to determine pressure prevalence, risk of mortality, and use of preventive measures in a group of hospitalized patients. Two hundred fifty-eight patients recruited from Skaraborg Hospital in Sweden were assessed. A 1-day point prevalence study was carried out using a protocol advocated by the European PU Advisory Panel. Patients' age, gender, severity of PU (grades I-IV), anatomical location of PU, and use of preventive measures were recorded. The Swedish language version of the Modified Norton Scale was used for PU risk assessment. Data were collected by nurses trained according to the Web-based training: PU classification, "ePuclas2." After 21 months, a retrospective audit of the electronic records for patients identified with pressure ulcers was completed. The point prevalence of pressure ulcers was 23%. The total number of ulcers was 85, most were grade 1 (n = 39). The most common locations were the sacrum (n = 15) and the heel (n = 10). Three percent of patients (n = 9) had been assessed during their current hospital stay using a risk assessment tool. There was a statistically significant relationship between pressure ulcer occurrence and a low total score on the Modified Norton Scale. The patients' ages correlated significantly to the presence of a pressure ulcer. Patients with a pressure ulcer had a 3.6-fold increased risk of dying within 21 months, as compared with those without a pressure ulcer. Based on results from this quality improvement project, we recommend routine pressure ulcer risk assessment for all patients managed in a hospital setting such as ours. We further recommend that particular attention should be given to older and frail patients who are at higher risk for pressure ulcer occurrence and mortality.

Nursing students' knowledge and attitude on pressure ulcer prevention evidence-based guidelines: a multicenter cross-sectional study

BACKGROUND

Pressure ulcers still remain a significant problem in many healthcare settings. Poor knowledge and negative attitudes toward pressure ulcer prevention could undesirably affect preventive care strategies.

OBJECTIVE

To assess both knowledge and attitudes among nursing students on Pressure Ulcer Prevention Evidence-Based Guidelines.

DESIGN

A multicenter cross-sectional survey was carried out from December 2012 to August 2013.

SETTINGS

The study was carried out in seven Italian nursing schools.

PARTICIPANTS

We involved a convenience sample of nursing students (n=742) METHODS: Data were collected using two validated questionnaires to assess students' knowledge and attitudes on pressure ulcer prevention.

RESULTS

The overall Knowledge and Attitude scores were 51.1% (13.3/26) and 76.7% (39.9/52), respectively. We found a weak correlation between total Knowledge scores and total Attitude scores (rho=0.13, p<0.001). We also observed that nursing students' year of education, training experience and number of department frequented during their clinical placement were significantly related to both the Knowledge and the Attitude total scores (p<0.05).

CONCLUSIONS

Nursing students' knowledge on pressure ulcer prevention was relatively low. However, we observed an association between a high level of education/training experience and higher knowledge scores. Most of the participants showed high attitude scores. These results suggest that positive attitudes toward pressure ulcer prevention may contribute to the compliance with the guidelines in clinical practice.

Oral treatment of pressure ulcers with polaprezinc (zinc L-carnosine complex): 8-week open-label trial

Polaprezinc (zinc L-carnosine complex) is a tablet commonly prescribed for gastric ulcers in Japan. Recently, we reported the effects of polaprezinc on pressure ulcer healing at 4-week follow-up. We aimed to further evaluate the efficacy and safety of polaprezinc in 8-week treatment for chronic pressure ulcers. Patients with stage II-IV pressure ulcers for ≥ 8 weeks received 150 mg/day polaprezinc (containing 116 mg L-carnosine and 34 mg zinc) per os for a maximum of 8 weeks. We measured the severity of pressure ulcers weekly using the Pressure Ulcer Scale for Healing (PUSH) score and monitored blood biochemistry. Fourteen patients (nine men; 68.4 ± 11.8 years) were enrolled. Pressure ulcer stages were II (one patient; 7 %), III (nine; 64 %), and IV (four; 29 %). The PUSH score improved significantly from 8.1 [95 % CI, 6.0-10.3] at baseline to -1.4 [-4.0 to 1.1] after 8 weeks (P < 0.001). Differences from baseline were significant after 1 week (P < 0.05). The mean weekly improvement in PUSH score was 2.0. Eleven patients healed within 8 weeks and none dropped out. Serum zinc levels increased significantly (P < 0.001), whereas serum copper levels (P = 0.001) and copper/zinc ratios (P < 0.001) decreased significantly. In one patient, preexisting copper deficiency deteriorated. These preliminary data suggest that polaprezinc may be effective and well-tolerated in 8-week treatment of pressure ulcers and could be a candidate for their oral treatment.

Prevalence and risk of pressure ulcers in acute care following implementation of practice guidelines: annual pressure ulcer prevalence census 1994-2008

Hospital-acquired pressure ulcers in the United States were estimated to cost US$2.2 to US$3.6 billion per year in 1999. In the early 1990s clinical practice guidelines for the prevention and treatment of pressure ulcers were introduced. The purpose of this study was to examine the epidemiology of pressure ulcers in acute care in Canada. The current study is based on 12,787 individuals who were inpatients during a 1-day annual census conducted in an acute care facility in Ontario between 1994 and 2008. The prevalence and incidence of pressure ulcer decreased slightly over time while the risk of pressure ulcer increased. The coccyx sacrum (~27%), heel (13%), ankle (~12%), and ischial tubersosity (~10%) were the most common ulcer sites. The implementation of clinical practice guidelines appears to have improved the quality of patient care, as demonstrated by increasing pressure ulcer risk while the prevalence and incidence of pressure ulcers has remained somewhat constant. From a policy perspective the importance of monitoring and tracking the risk and occurrence of this adverse event provides a general indicator of care, considering the many organizational aspects that may ameliorate risk.

A multi-center, randomized, clinical trial comparing adhesive polyurethane foam dressing and adhesive hydrocolloid dressing in patients with grade II pressure ulcers in primary care and nursing homes

Background

Pressure ulcers (PrUs) are ischemic wounds in the skin and underlying tissues caused by long-standing pressure force over an external bone or cartilaginous surface. PrUs are an important challenge for the overall health system because can prolong patient hospitalization and reduce quality of life. Moreover, 95% of PrUs are avoidable, suggesting they are caused by poor quality care assistance. PrUs are also costly, increasing national costs. For example, they represent about 5% of overall annual health expenses in Spain. Stages I and II PrUs have a combined prevalence of 65%. According main clinical guidelines, stage II PrUs (PrU-IIs) are usually treated by applying special dressings (polyurethane or hydrocolloid). However, little scientific evidence regarding their efficacy has been identified in scientific literature. Our aim is to assess the comparative efficacy of adhesive polyurethane foam and hydrocolloid dressings in the treatment of PrU-IIs in terms of healed ulcer after 8 weeks of follow-up.

Methods/design

This paper describes the development and evaluation protocol of a randomized clinical trial of two parallel treatment arms. A total of 820 patients with at least 1 PrU-II will be recruited from primary health care and home care centers. All patients will receive standardized healing procedures and preventive measures (e.g. positional changes and pressure-relieving support surfaces), following standardized procedures. The main outcome will be the percentage of wounds healed after 8 weeks. Secondary outcomes will include cost-effectiveness, as evaluated by cost per healed ulcer and cost per treated patient and safety evaluated by adverse events.

Discussion

This trial will address the hypothesis that hydrocolloid dressings will heal at least 10% more stage II PrUs and be more cost-effective than polyurethane foam dressings after 8 weeks.

Trial registration

This trial has been registered with controlled-trials number ISCRCTN57842461 and EudraCT 2012-003945-14.

The prevalence of pressure ulceration among Jordanian hospitalised patients

OBJECTIVE

To measure the prevalence rate of pressure ulcers (PUs) among hospitalised patients and to assess the adequacy of preventative care provided to patients at-risk for PUs.

METHOD

A cross-sectional survey was conducted by inspecting the skin of each patient included; if a PU was noted, it was classified according to the European Pressure Ulcer Advisory Panel grading system. Risk was assessed using the Braden scale and the use of preventative interventions was also documented.

RESULTS

The sample included was 295 patients; mean age of the patients was 49.1 +/- 18.6 years (range 18-87 years) and 55% (n = 162) were male. The prevalence rate was 16% (8.8% excluding category I). Category I was the most common grade of PU (n = 22; 46%). The heels were the most commonly affected sites (n = 23; 49%). Only 19% of patients in need of prevention actually received proper adequate prevention.

CONCLUSION

PU prevalence rate was lower than published rates in studies that employed the same method. The young age and general health of our sample could be the best explanation. A very small percentage of at-risk patients receive adequate prevention. This should open the door to scrutinising the provision of PU prevention in Jordan.

Effects of L-carnosine and its zinc complex (Polaprezinc) on pressure ulcer healing

BACKGROUND

L-carnosine (CAR) is an endogenous dipeptide. We aimed to determine the effects of CAR and its zinc complex polaprezinc (PLZ) on pressure ulcer healing in institutionalized long-term care patients.

METHODS

This study was a nonrandomized controlled trial with a maximum 4-week follow-up. Forty-two patients with stage II-IV pressure ulcers for 4 or more weeks were allocated to 1 of 3 groups in order of recruitment: the control group (n = 14) was untreated, the PLZ group (n = 10) orally received 150 mg/d PLZ (containing 116 mg CAR and 34 mg zinc), and the CAR group (n = 18) orally received 116 mg/d CAR. Pressure ulcer severity was measured weekly using the Pressure Ulcer Scale for Healing (PUSH) score.

RESULTS

At baseline, no significant differences were found among groups in demographic and nutrition parameters and pressure ulcer characteristics (severity, size, and staging). After 4 weeks, the rate of pressure ulcer healing, assessed by the mean weekly improvement in PUSH score, was significantly greater in the CAR (1.6 ± 0.2, P = .02) and PLZ groups (1.8 ± 0.2, P = .009) than in the control group (0.8 ± 0.2). The difference between the CAR and PLZ groups was not significant (P = .73). Actual dietary intakes over this period did not differ significantly among groups.

CONCLUSIONS

Our results suggest that CAR and PLZ may almost equally accelerate pressure ulcer healing during 4 weeks. The results need confirmation by randomized controlled trials with larger sample sizes.

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9-year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual-care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital-acquired pressure ulcers decreased following implementation of an evidence-based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual-care nurses under-estimated patients' risk of pressure ulcer development and under-utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital-acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.

[Prevalence of pressure ulcers in the the Balearic Islands]

OBJECTIVE

The absence of reliable information regarding Pressure Ulcers in the Balearic Islands has led to the development of this study. The main objective was to acquire knowledge of the prevalence in hospitals, nursing homes and patients who have received domiciliary care in the public and semi-private services.

METHODS

It is a descriptive, cross-sectional and observational prevalence study. Data of the whole population (2,454 patients) was collected in hospitals and nursing homes. A stratified systematic randomized sampling was carried out in domiciliary care (342 patients). The information was gathered by specially trained nurses, through direct observation, checking of individual health records and interviews. Data was collected and processed through a computing system with PDA support.

RESULTS

A total of 43.8% of the patients were at risk. The crude prevalence was 12.7% and in patients at risk, 28.3%. The prevalence was higher within the group of people aged more than seventy. Injuries in the sacrum and heels exceeded 60%. Except for medium and long-stay hospitals, more than 70% of the patients with pressure ulcers had developed some ulcer in the centre where they were being cared for.

CONCLUSIONS

It can be concluded that in the Balearic Islands, pressure ulcers are a significant health problem. The quality of healthcare can be potentially improved at every care level. The difference in the methodology used in prevalence studies of prevalence suggests that there is a need to work towards a more standardised information system and to reach a consensus with all the Spanish regions.

The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009

OBJECTIVE

Suspected deep tissue injury (sDTI) was identified in 2001 and added as a staging definition by the National Pressure Ulcer Advisory Panel in 2007. Clinical data on sDTI are sparse. This article reports the overall prevalence data and describes the demographics of subjects with sDTI from the International Pressure Ulcer Prevalence survey 2006-2009.

METHODS

Participating healthcare facilities performed prevalence surveys in their facility during a pre-determined 24-hour period within a pre-selected 2- to 3-day window. All generated data was incorporated into the database, even if specific data fields were absent.

RESULTS

Approximately 79,000 to 92,000 patients were surveyed each year from 2006 to 2009. The overall and nosocomial pressure ulcer (PrU) prevalence decreased by approximately 1% in 2009 (P < .001), after remaining fairly constant in the years 2006-2008. The proportion of ulcers identified as sDTI has increased 3 fold, to 9% of all observed ulcers in 2009 and is more prevalent than either Stage III or IV ulcers. Over the same period, the proportion of Stage I and II ulcers have decreased, and the proportion of Stage III and IV ulcers has remained nearly constant. Patients with sDTIs are older than patients with Stage III, IV, and Unstageable ulcers. The anatomic location of sDTIs are more commonly found at the heel (41%), the sacrum (19%), or the buttocks (13%). Compared with other staged ulcers, sDTIs are significantly more prevalent at the heel (P < .001) and the ankle and foot (P < .001) and less prevalent at the sacrum and coccyx (P < .001) and at the buttocks and ischial tuberosities (P < 0.001).

CONCLUSION

The survey data indicate that a decrease in overall prevalence of PrUs, as well as hospital-acquired PrUs, may have occurred in 2009. Suspected deep tissue injuries have become more commonly identified, which may be secondary to education of staging definitions.

Profile and severity of the patients of intensive care units: prospective application of the APACHE II index

This study aimed to understand the profile and severity of patients in physiotherapy treatment after their admission to the intensive care unit (ICU) by applying the APACHE II index. One hundred and forty six subjects, with a mean age of 60.5 +/- 19.2 years, were evaluated. The APACHE II index was applied in the first 24 hours to evaluate the severity and mortality risk score. Patients were monitored until hospital discharge or death. The mean APACHE II score was 20+/-7.3 with an estimated risk of death of 32.4% and observed mortality of 58.2%. The mean hospital stay was 27.8+/-25.2 days. The patients in physiotherapy at the institution studied were predominantly male, elderly, from the emergency service for treatment (non-surgical), and had clear severity, suggested by the APACHE II score and the observed mortality.

Pressure ulcers: development and psychometric evaluation of the attitude towards pressure ulcer prevention instrument (APuP)

BACKGROUND

Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking.

AIMS AND OBJECTIVES

Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP).

DESIGN

Prospective psychometric instrument validation study.

METHODS

A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008.

RESULTS

A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC=0.88 (95% CI=0.84-0.91, P<0.001)]. For the total instrument, the internal consistency (Cronbachs alpha) was 0.79.

CONCLUSION

The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored.

Effectiveness of instituting a specific bed protocol in reducing complications associated with bed rest

Pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia are well-known complications of bed rest. This retrospective, single-center, observational cohort study evaluated the effectiveness of instituting bed rest protocol that included specific positioning, continuous heel off-loading, recumbent upper and lower body bed exercises, scheduled incentive spirometry, frequent position changes, and thromboprophylaxis (chemical, mechanical, or both), in reducing the incidence of pressure ulceration, deep venous thromboembolism, and hospital-acquired pneumonia in consecutive patients admitted for at least 7 days. A total of 29 patients (24 males, 5 females) were included in this study, with a mean age of 62.5 (median 63, range 17 to 84) years. The mean length of bed rest was 13.1 (median 10, range 7 to 31) days; and, the mean length of hospital stay was 21.1 (median 17, range 8 to 72) days. During hospitalization, 2 (6.9%) patients developed one or more of the complications measured, with 1 developing a posterior heel pressure ulcer that resolved with local care and another who developed deep venous thrombosis without pulmonary embolism, managed with therapeutic anticoagulation, and hospital-acquired pneumonia treated with antibiotic therapy. The results of this analysis were favorable in comparison with previously reported incidence rates for pressure ulcer, deep venous thrombosis, and hospital-acquired pulmonary complications in patients with similar risk factors, and suggested that a prescribed bed protocol reduces complications associated with bed rest.

[Incidence and risk factors associated with the presence of pressure ulcers in critically ill patients]

OBJECTIVE

The incidence of pressure ulcers in the literature varies from 4.7% to 18.6%. In our study, we have aimed to identify the incidence and risk factors associated with the occurrence of pressure ulcers in critically ill patients.

SCOPE

Medical-surgical intensive care unit.

DESIGN

Prospective observational study in the period of September 2005 to August 2006.

PATIENTS AND METHODS

We included patients without PU on admission who were hospitalized more than 48 hours in the intensive care unit (ICU) and who had any of the following risk factors for pressure ulcers: intubated and on mechanical ventilation, with vasopressor support. Main variable interest: The main variable was the presence of grade II or higher PU. Other variables studied were age, weight, body mass index, admission diagnosis, presence of infection, APACHE II (Acute Physiologic and Chronic Health Evaluation), ventilation mechanical level of sedation, presence of diarrhea, wound drainage, vasopressor support, duration of mechanical ventilation, ICU and hospital stay.

RESULTS

The study included 150 patients, with an average age of 54 years, the APACHE II averaged 18.2+/-8.2, 88.67% of the patients were on mechanical ventilation, days of stay in ICU were an average of 11.94+/-16.45. Percentage of PU grade II or higher was 26.7%. After the univariate analysis, the risk factors found were presence of infection (OR=2.52 with a p-value=0.013 and a 95% CI, 1.2-5.29), days of stay in ICU (p=0.001; OR=4.39; 95% CI, 6.92-18.25). Presence of infection (OR=2.89; p=0.023; 95% CI, 1.16-7.22), days of stay in the ICU (OR=1.13; p=0.005; 95% CI, 1.06,1.22) and a high score APACHE II (OR=1.06; p=0.044; 95% CI, 1-1.12) were also significant in the multivariate analysis.

CONCLUSIONS

The incidence of pressure ulcers in the study population is very high. The risk factors most often found are presence of infection, days of stay and high APACHE II score.

Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment--a survey in a Swedish healthcare setting

The aim of this study was to investigate (i) attitudes among Registered Nurses (RNs) and Nursing Assistants (NAs) regarding pressure ulcer prevention, (ii) knowledge among RNs and NAs of pressure ulcer prevention and treatment, (iii) practice of risk assessment and documentation regarding pressure ulcers among RNs and NAs and (iv) to identify perceived possibilities and barriers in pressure ulcer prevention and treatment. In this cross-sectional study, a total of 230 questionnaires were distributed to an equal number of RNs and NAs in both municipality as well as hospital care settings. The response rate was 67% (n = 154). In general, all respondents displayed good knowledge on prevention and treatment of pressure ulcers and demonstrated a positive attitude towards this area of care. However, answers provided to some questions indicate that recent research findings and guidelines have not succeeded in reaching out to these occupational groups. Furthermore, only 37% (n = 55) of the participants said that they have an agreed strategy for the prevention of pressure ulcers in their unit. These shortcomings may affect the quality of care provided to the patient and lead to pressure ulcers developing as a consequence. Today, evidence-based methods for risk assessment are available but are not adopted and used in practice. The study highlights the need to further reduce the gap between research and practice.

Prospective study: reducing pressure ulcers in intensive care units at a Turkish medical center

PURPOSE

The purpose of this study was to determine the impact of an educational intervention on the incidence of stage II pressure ulcers (PUs) in adult patients in intensive care units (ICUs) in a Turkish medical center.

DESIGN

This was a prospective study of patients admitted to ICUs. Data were collected over a 3-month period. Subjects were assessed using the Braden Scale for Predicting Pressure Sore Risk to determine the risk for developing a PU; assessment was completed within the first 24 hours of admission and each 48 hours thereafter for a maximum of 12 weeks. Educational intervention was employed: Intervention included education of ICU nurses about PU prevention and risk assessment; and following the educational intervention and implementation of the PU prevention protocol in all ICUs, data were collected for study period II.

SUBJECTS AND SETTING

The sample comprised 186 patients admitted to critical care units of a Turkish medical center. Ninety-three subjects participated in a preintervention comparison group, and 93 subjects participated in an intervention group.

INSTRUMENTS

Data were collected using a demographic and clinical data form, a nursing intervention checklist, and the Braden Scale for Predicting Pressure Sore Risk.

RESULTS

Stage II PUs were observed in a total of 50 patients for the overall sample. The most common site was the sacrococcygeal area, which accounted for 46% of ulcers. A statistically significant difference was observed when the rate of stage II PUs in the comparison group, 37% (34 of 93 patients), was compared to the rate in the intervention group, 17% (16 of 93 patients) (chi2 = 8.86, df = 1, P < .01).

CONCLUSION

Education regarding preventive care can be effective in reducing the incidence of PUs in the ICU setting. Therefore, education about risk assessment and PU prevention should be a priority for nurses in critical care settings.

Using the Braden and Glasgow scales to predict pressure ulcer risk in patients hospitalized at intensive care units

Pressure ulcers remain a major health issue for critical patients. The purpose of this descriptive and exploratory study was to analyze the risk factors for the development of pressure ulcers in patients hospitalized at an intensive care unit of a university hospital. Patients were assessed through the Braden scale to determine the risk for the development of pressure ulcers and to identify individual risks, and the Glasgow scale was used to assess their consciousness. It was found that the risks associated with pressure ulcer development were: low scores on the Braden Scale on the first hospitalization day and low scores on the Glasgow scale. The results showed that these tools can help nurses to identify patients at risk, with a view to nursing care planning.

Tracking quality over time: what do pressure ulcer data show?

OBJECTIVE

To compare the prevalence of pressure ulcers and prevention before and after a quality improvement program; determine whether patient characteristics differed for those who did and did not develop pressure ulcers; identify pressure ulcer prevention implemented at admission and whether prevention and risk factors varied by pressure ulcer severity.

DESIGN

Descriptive comparative study based on two cross-sectional pressure ulcer surveys conducted in 2002 and 2006, complemented with a retrospective audit of the electronic health record and administrative system for patients identified with pressure ulcers.

SETTING

1100-bed Swedish university hospital.

PARTICIPANTS

612 hospitalized patients in 2002 and 632 in 2006.

MAIN OUTCOME MEASURES

Prevalence of pressure ulcers and prevention (pressure-reducing mattresses; planned repositioning; chair, heel and 30 degrees lateral positioning cushions).

RESULTS

Pressure ulcer prevalence was 23.9% in 2002 and 22.9% in 2006. When non-blanchable erythema was excluded, the prevalence was 8.0 and 12.0%, respectively. The use of pressure-reducing mattresses increased while planned repositioning decreased. Those who developed ulcers were older, at-risk for ulcers, incontinent and had longer length of stay. Little prevention was documented at admission. Some prevention strategies and risk factors were related to severity of ulcers.

CONCLUSIONS

Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Special attention is needed to provide prevention to older patients with acute admission. Skin and risk assessment, as well as prevention, should start early in the hospitalization. Identifying those persons with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported by ward level for comparison over time.