Adapting Pressure Ulcer Prevention for Use in Home Health Care

Preventive care for individuals with deep pressure ulcers in Sweden living at home: A cross-sectional study

Background and Aims

Several factors exist regarding the risk for, healing and prevention of pressure ulcers (PUs). A mobile PU team with an individualized holistic approach adapted to the home or outpatient clinic setting could be beneficial for the prevention, and management of PUs.

Aims

To describe the mobile PU team's interventions among individuals who had deep PUs and were living at home. Another aim was to describe the patients' perceptions of the quality of the care and having a deep PU.

Methods

A quantitative study with a cross-sectional design. At an outpatient clinic, a mobile PU team was established to perform and follow up PU prevention interventions and advanced wound care treatment at home and at the outpatient clinic. All adult patients with existing deep category four PUs remitted to the outpatient clinic were asked to participate, and 16 out of 24 individuals consented. Instruments used for data collection were "Quality from the Patient's Perspective," "Wound-Quality of Life," "Modified Norton Scale," and a study developed protocol for the mobile team's PU interventions.

Results

The patients chose home visits 20 times and outpatient clinic visits 89 times. In total, 8-13 interventions per participant were performed by the mobile team. The results show that having PUs affected the participants' perceptions of care and general well-being. The PUs did not heal completely but they did improve, six patients underwent flap surgery.

Conclusion

When organizing care regarding patient safety for patients with deep PUs, it is important to consider the patient's perspective and well-being and to involve patients in their care plans. Home care is perhaps not the only way of caring; other aspects, in addition to telemedicine, could be an option.

Prevalence of Pressure Injury among Stroke Patients In and Out of Healthcare Settings: A Systematic Review and Meta-Analysis

Pressure injury is a recognized problem for patients with stroke. Knowing the prevalence of pressure injury post stroke can guide clinical professionals and researchers to take appropriate actions for patient care and education. The aim of this study was to systematically review the literature regarding prevalence of pressure injury among patients with stroke in the hospital, and in the home with no home healthcare services and nursing homes. Original articles available in Scopus, Web of Science, PubMed, ProQuest, and Google Scholar databases were searched separately by two researchers using the following keywords: stroke, cerebrovascular attack, pressure injury, pressure ulcer, bedsore, decubitus ulcer, and prevalence. The search was performed according to the PRISMA flow diagram from 2000 to 2020. After the initial review, 14 articles conducted between 2008 and 2019 were included in the final analysis. Eight studies were conducted in healthcare settings, and six studies were conducted out of hospitals. The estimated pooled prevalence for pressure injury in all studies was 3.9%. The estimated pooled prevalence for pressure injury in studies conducted in hospitals and in patients' homes with no home healthcare services and nursing homes were 3.06 and 17.25, respectively. The prevalence of pressure injury among stroke patients after hospital discharge was significantly higher than when they were hospitalized. This could indicate that this group of patients do not receive adequate care and attention for pressure injury after hospital discharge. Given the limitations of the available studies, it is recommended that further studies be conducted on pressure injury among stroke patients both at the time of hospitalization and after hospital discharge.

Formal Caregiver Experiences of Caring for Individuals at Risk for or with a Pressure Injury: A Metasynthesis

OBJECTIVE

To explore formal caregiver experiences caring for patients with a pressure injury (PI) or who are at risk of developing a PI.

DATA SOURCES

In November 2019, the researchers searched CINAHL (Cumulative Index to Nursing and Allied Health Literature) and MEDLINE databases for articles related to caregivers and their experiences with PI prevention and care.

STUDY SELECTION

Twenty-eight qualitative studies were included in this review.

DATA EXTRACTION

Literature was graded and critiqued with regard to design and research quality and then synthesized utilizing a narrative approach.

DATA SYNTHESIS

Four themes were found within the literature: knowledge and education, environment and resources, collaboration and role clarity, and risk assessment.

CONCLUSIONS

Across healthcare settings, formal caregivers noted the importance of effective PI knowledge and education. Recognizing both barriers and facilitators to PI prevention and management within the healthcare environment can help decision-makers make informed choices to improve PI management within their settings. In addition, developing interprofessional team skills and relationships, rather than practicing in silos, may have an impact on PI management. Although there are many interventions that reduce PI risk and assist in the management of PIs, not every intervention is appropriate for every healthcare setting. Clinician education on PIs, along with new interventions, could significantly impact the effectiveness of patient care.

The Role of Family Caregivers in Pressure Injury Prevention Guidelines: A Scoping Review

Considering the importance of family caregivers in pressure injury prevention, it is necessary to clearly define their role in pressure injury prevention guidelines. We reviewed the contents of pressure injury prevention guidelines with the aim of defining the role of family caregivers. PubMed, Web of Science, Scopus, and Proquest were searched, as well as the internet, as some pressure injury guidelines may not be published in professional journals. Literature published between 2000 and 2020 was searched using the keywords "pressure injury," "pressure ulcer," "bed sore," and "prevention guideline." Ten guidelines related to pressure injury prevention were found. Of these, five guidelines mentioned the role of family caregivers in relation to pressure injury, referring only to the training and empowerment of family caregivers. Of the five guidelines that mentioned caregiver training, only three determined the training content in detail. According to these guidelines, family caregivers should be trained on the risk factors of pressure injuries, characteristics of pressure injuries, intervention to prevent pressure injuries, nutrition, sign and symptoms of pressure injuries, complication such as infection and using protective equipment and devices. In the guidelines that focused on family caregivers, the attention is sometimes limited and vague. Limited attention to the role of family caregivers can lead to lack of awareness and reduced ability of family caregivers to prevent pressure injury and ultimately increase the patient's risk of developing pressure injury.

Convergent Validity of Three Pressure Injury Risk Assessment Scales: Comparing the PPRA-Home (Pressure Injury Primary Risk Assessment Scale for Home Care) to Two Traditional Scales

Purpose

The Pressure Injury Primary Risk Assessment Scale for Home Care (PPRA-Home) was developed to predict pressure injury risk in geriatric individuals requiring long-term care in home settings. This study aimed to compare the convergent validity of the PPRA-Home to that of the two other standardized pressure injury prevention scales: the Braden and Ohura-Hotta (OH) scales.

Methods

A multicenter, cross-sectional study was conducted with 34 home-based geriatric support service providers located in five Japanese districts. The study included 69 participants (30 had a pressure injury and 39 did not) who were at classified at care levels of 1 through 5 under Japan’s long-term care insurance system. Care managers served as assessors for the PPRA-Home, while physicians or certified expert nurses served as assessors for the Braden and OH scales. Convergent validity was investigated by examining correlation coefficients between total scores on the PPRA-Home and the other two scales. Receiver operating curve analysis was used to quantify each scale’s accuracy for the two groups: those with and without a pressure injury.

Results

The PPRA-Home was found to be negatively correlated with the Braden scale (r=−0.79, p<0.05), and positively correlated with the OH scale (r=0.58, p<0.05). The area under the curve (AUC) for the PPRA-Home, Braden scale, and OH scale were 0.737, 0.814, and 0.794, respectively. A PPRA-Home cutoff score of 4 had a sensitivity of 63.3% and specificity of 81.6%.

Conclusion

The AUC for the PPRA-Home as scored by care managers was similar to those of the Braden and OH scales as scored by physicians or expert nurses. More research on the PPRA-Home’s content and predictive validity is required.

An interprofessional approach to pressure ulcer prevention: a knowledge and attitudes evaluation

Background: Pressure ulcers (PUs) are a major burden to individuals, impacting their physical, mental and social wellbeing. While PU prevention is traditionally regarded as a nursing issue, an interprofessional approach has been promoted as best practice. However, little is known about current practice or the knowledge and attitudes of the wider interprofessional team (IPT). Purpose: Pre-designed questionnaires were used to explore knowledge and attitudes with healthcare staff in the community. Methods: Questionnaires were disseminated to all healthcare staff within a community healthcare Trust predominantly via an online tool. Data were analyzed using descriptive and inferential statistics. Results: The median values of all professional groups demonstrated satisfactory attitudes (>75%) and levels of knowledge (>60%) to PU prevention. However, there were differences within and between groups. Management staff demonstrated the most positive attitude to PU prevention (89%), followed by occupational therapists (OTs) and healthcare assistants (HCAs) (87%, IQR: 75%→89%). OTs demonstrated the highest scores for knowledge (69%, IQR: 62%→73%), while healthcare and rehabilitation assistants scored the lowest (58%, IQR: 58%-64%). Conclusion: This study has demonstrated that the majority of healthcare staff in a UK community setting have satisfactory levels of knowledge and attitudes in relation to PU prevention overall. Nevertheless, there were some differences between groups, albeit non-significant. There were also differences between sub-themes of the questionnaires, indicating a greater focus of pressure ulcer treatment over prevention. While PU prevention is widely regarded to be a nursing issue, these findings provide some indication of the potential for an interprofessional approach.

Ensuring healthy skin as part of wound prevention: an integrative review of health professionals' actions

OBJECTIVE

To provide a synthesis of the best available, recent primary or secondary research evidence on early preventative activities taken to increase skin health, and reduce the incidence of facility-acquired skin tears and pressure ulcers (PUs) in community, residential and health-care institutions.

METHOD

An integrative review focusing on a 10-year period, 2007-2017. A literature search of health databases was carried out, as well as a search of grey literature in relevant skin, wound care and nursing association journals. A second search was also conducted focused on literature from policy and guideline development organisations. Primary outcomes of interest were reduction in dry skin (xerosis), friable skin, or increases in healthy skin maintenance activities. Secondary outcomes of interest were reductions in PU or skin tear occurrences. Opinion, non-systematic literature reviews and discussion papers were excluded.

RESULTS

Of the 4932 references obtained from the searches, a total of 33 articles were included in the review: 27 peer-reviewed journal articles and six articles from the grey literature search. No guideline was found that focused on maintaining skin health as a person ages. Studies identified the main factors for maintaining skin health as nutrition, hydration and skin care regimen.

CONCLUSION

Skin care regimens, including a focus on good nutrition and pH balance, should start immediately on arrival in institutions such as hospitals or residential aged care, and continue throughout the stay.

Nurses' perceptions of the root causes of community-acquired pressure ulcers: Application of the Model for Examining Safety and Quality Concerns in Home Healthcare

AIMS AND OBJECTIVES

To explore how the context of care influences the development of community-acquired pressure ulcers from the perspective of nurses working in home healthcare settings, to identify and categorise the factors perceived as contributing to the development of these ulcers using the Model for Examining Safety and Quality Concerns in Home Healthcare, and to explore how these risks are managed in practice.

BACKGROUND

Pressure ulcer reduction is a priority in both hospital and community settings. Evidence suggests the factors affecting safety and performance in community settings are not the same as in hospital. However, research pertaining to pressure ulcer risk management has predominantly been undertaken in hospital settings.

DESIGN

The study was framed by a qualitative exploratory design.

METHODS

Semistructured interviews were conducted with a purposive sample of 19 registered nurses recruited from an independent regional tissue viability network and five community nursing provider organisations in London.

RESULTS

The experiences and perceptions of participants mapped onto the components of the Model for Examining Safety and Quality Concerns in Home HealthCare: patient characteristics, provider characteristics, nature of home healthcare tasks, social and community environment, medical devices and new technology, physical environment, and external environment. Four strategies to address identified risks were established: behavioural interventions, technical interventions, safeguarding interventions and initiatives to promote better integration between health, local authorities and families.

CONCLUSION

Understanding the complex interplay between people and other elements of the healthcare system is critical to the prevention, management and investigation of pressure ulcers. This study has illuminated these elements from the perspective of nurses working in community settings.

RELEVANCE TO CLINICAL PRACTICE

Further consideration should be given to the importance of place when both developing risk management strategies for pressure ulcer prevention and learning the lessons from failure.

The use of prophylactic dressings in the prevention of pressure ulcers: a literature review

Pressure ulcers pose a significant burden to both patients and health care resources. There are an increasing number of studies that have examined the use of prophylactic dressings, and their ability to redistribute pressure and protect the skin from shear and friction damage. This literature review examines six studies conducted on this controversial subject. Brindle and Wegelin ( 2012 ; Chaiken, 2012 ; Cubit et al, 2012 ; Santamaria et al, 2012) all examined the role of dressings to prevent pressure ulcers, and Call et al (2013a ; 2013b ), conducted in vitro research into the mode of dressings. Current research suggests that while further research is required, the use of prophylactic dressings have a place alongside standard measures, in helping to prevent pressure, shear and friction damage.

A longitudinal qualitative study of health care personnel's perceptions of simultaneous implementation of three risk assessment scales on falls, malnutrition and pressure ulcers

AIMS AND OBJECTIVES

In this study, the aim was to understand health care personnel's expectations and experiences of participating in an intervention aimed at the implementation of three assessment scales for fall injuries, malnutrition and pressure ulcers, and the performance of preventive measures in these areas over the period of 18 months.

BACKGROUND

Fall injuries, malnutrition and pressure ulcers among older people are challenging issues for caregivers at different levels in the health care system.

DESIGN

A descriptive design with a qualitative approach was used to follow health care personnel before, during and after implementation of a care prevention intervention.

METHODS

Twelve health care personnel with different professions at the hospital, primary care and municipal care levels participated in a preventive care introduction. Seminars were held at four occasions, with assignments to be completed between seminars. Lectures and group discussions were performed, and three risk assessment scales were introduced. The participants were interviewed before, during and after the introduction. Manifest and latent content analysis were used.

RESULTS

The main results are presented in the theme 'Patient needs are visualised through a gradually developed shared understanding' and in five categories. The work approach of performing three risk assessments simultaneously was perceived as positive and central to ensuring quality of care; it was not, however, perceived as unproblematic.

CONCLUSION

The participants as well as health care team members showed a positive attitude towards and described the advantages of being given opportunities for shared understanding to improve patient safety and to provide structure for the provision of good care.

RELEVANCE TO CLINICAL PRACTICE

The managerial approach of listening to and acting on issues stressed by health care personnel is important to ensure ongoing and future improvement initiatives.