Preventing Hospital-Acquired Pressure Ulcers: Improving Quality of Outcomes by Placing Emphasis on the Braden Subscale Scores

Sensor Cell Network for Pressure, Temperature and Position Detection on Wheelchair Users

This work proposes an optical sensing network to monitor pressure and temperature in specific areas of a wheelchair to prevent pressure ulcers and to monitor the position of the wheelchair user by analyzing its pressure distribution. The sensing network is composed of six optical fiber Bragg grating (FBG)-based sensor cells. Each sensor cell is built from a polylactic acid (PLA) base and has two FBGs, one embedded in epoxy resin to monitor pressure variations (FBG_P) and another without resin to monitor temperature (FBG_T). Once produced, all sensor cells were experimentally characterized for pressure and temperature variations, resulting in an average pressure sensitivity of 81 ± 5 pm/kPa (FBG_P) and −5.0 ± 0.4 pm/kPa (FBG_T), and an average temperature sensitivity of 25 ± 1 pm/°C (FBG_P) and 47.7 ± 0.7 pm/°C (FBG_T). The sensor cells were then placed in six specific areas of a wheelchair (four in the seat area and two in the shoulder blade area) to carry out experimental tests, wherein the response of the sensors to a specific sequence of relief positions was tested. During the execution of the test, the optical signal of all sensors was monitored, in real time, with the pressure and temperature values detected in each zone of the wheelchair. In addition, random position changes were performed in order to evaluate the precision of the proposed sensing network in the identification of such positions.

Implementation of a Nurse Driven Pathway to Reduce Incidence of Hospital Acquired Pressure Injuries in the Pediatric Intensive Care Setting

PURPOSE

A large, freestanding pediatric hospital in the southern United States saw a 117% increase in reported hospital acquired pressure injuries (HAPI) between 2013 and 2015, with the intensive care units being the units of highest occurrence. Design and Methods A quality improvement project was designed and implemented to assist with pressure injury prevention. Literature review confirmed that pediatric HAPIs are a challenge and that usage of bundles and user-friendly guidelines/pathways can help eliminate barriers to prevention. The aim of this quality improvement project had two aims. First, to reduce HAPI incidence in the PICU by 10%. Second, to increase consistent usage of pressure injury prevention strategies as evidenced by a 10% increase in pressure injury bundle compliance. The third aim was to identify if there are differences in percentage of interventions implemented between two different groups of patients. Donabedian's model of Structure, Process, and Outcomes guided the development and implementation of this quality improvement project. Interventions focused on risk assessment subscale scores have the opportunity to mitigate specific risk factors and improve pressure injury prevention.

RESULTS

Through implementation of the nurse driven pathway there was as 57% decrease in reported HAPIs in the PICU as well as a 66% increase in pressure ulcer prevention bundle compliance.

CONCLUSIONS

Implementation of the nurse driven pressure injury prevention pathway was successful. There was a significant increase in bundle compliance for pressure ulcer prevention and a decrease in reported HAPIs.

PRACTICE IMPLICATIONS

The pathway developed and implemented for this quality improvement project could be adapted to other populations and care settings to provide guidance across the continuum.

SIRA+P: Development and Testing

OBJECTIVES

To describe the development of a new skin risk assessment scale called Skin Injury Risk Assessment and Prevention (SIRA+P) and to establish initial reliability and validity of the scale among patients ranging in age from birth, including pre-term, to adulthood, regardless of age or acuity of illness.

STUDY DESIGN

The single-site study was a retrospective chart review to evaluate the measurement properties of SIRA+P. Charts of 385 patients of all ages and in all units (including the neonatal and pediatric intensive care units) of a free-standing children's hospital were included. Concurrent validity was assessed with scales having previously established reliability and validity. For subjects <30days of age, the comparison scale was the Neonatal Skin Risk Assessment Scale (NSRAS); for subjects 31days through 17years, the Braden Q Scale (Braden Q) was used; and for subjects 18years and older, the Braden Scale (Braden) was used. Interrater reliability was examined using Intraclass Correlation Coefficients (ICC). Concurrent validity procedures compared SIRA+P with NSRAS, Braden Q, and Braden using Pearson Correlation Coefficients.

RESULTS

Interrater reliability for SIRA+P was very high (0.878). SIRA+P strongly correlated with the NSRAS (0.725), the Braden Q (-0.634), and the Braden (-0.778).

CONCLUSION

SIRA+P is designed to be used within the EHR and includes nursing decision support to guide pressure injury prevention interventions for specific skin integrity risks. SIRA+P has good interrater reliability, is valid across all age groups and accounts for device-related pressure.

The Use of the Braden Scale in Assessing Pressure Ulcers in Turkey: A Systematic Review

OBJECTIVE

The goal of this systematic review was to reach scientific generalizations regarding the assessment of risk for pressure ulcers based on the results of previous studies that made use of the Braden Scale.

DATA SOURCES

This research was performed by using a retrospective screening of studies relevant to the subject. In Turkey, the first validity and reliability study for the Braden Scale was performed by Oğuz and Olgun in 1998. For this reason, the authors' research was conducted between March 2, 2012, and August 4, 2012, as a systematic review analysis by evaluating studies in Turkey that made use of the Braden Scale between 1998 and 2012. Screening was performed by using different combinations of 8 keywords in Turkish and English to scan a total of 10 national and international databases. A total of 2375 studies were evaluated, and 16 studies were included and considered within the context of this research.

RESULTS AND CONCLUSIONS

It was determined that the studies considered within the context of the current research were conducted between 1998 and 2012; 5 of these studies were experimental and 11 were descriptive; the sample size varied between 22 and 422; the majority were performed in intensive care units; and the study samples were mostly composed of patients. The Braden Scale was used in these studies for forming samples by identifying high-risk patients. Two studies evaluated the reliability of the Braden Scale, whereas 7 other studies calculated the reliability coefficient. Only 1 study included results for sensitivity, specificity, positive predictive value, and negative predictive value (which represent the predictive criteria of assessment tools). Four studies indicated cutoff values, which varied between 14 and 18. A general evaluation of these studies' results revealed limited evidence of effective risk assessment by the Braden Scale.

Identifying the right surface for the right patient at the right time: generation and content validation of an algorithm for support surface selection

Support surfaces are an integral component of pressure ulcer prevention and treatment, but there is insufficient evidence to guide clinical decision making in this area. In an effort to provide clinical guidance for selecting support surfaces based on individual patient needs, the Wound, Ostomy and Continence Nurses Society (WOCN®) set out to develop an evidence- and consensus-based algorithm. A Task Force of clinical experts was identified who: 1) reviewed the literature and identified evidence for support surface use in the prevention and treatment of pressure ulcers; 2) developed supporting statements for essential components for the algorithm, 3) developed a draft algorithm for support surface selection; and 4) determined its face validity. A consensus panel of 20 key opinion leaders was then convened that: 1.) reviewed the draft algorithm and supporting statements, 2.) reached consensus on statements lacking robust supporting evidence, 3.) modified the draft algorithm and evaluated its content validity. The Content Validity Index (CVI) for the algorithm was strong (0.95 out of 1.0) with an overall mean score of 3.72 (out of 1 to 4), suggesting that the steps were appropriate to the purpose of the algorithm. To our knowledge, this is the first evidence and consensus based algorithm for support surface selection that has undergone content validation.

[Association of Braden subscales with the risk of development of pressure ulcer]

Pressure ulcers (PU) may increase the incidence of hospital complications, and one should prevent this damage. The Braden Scale stands out as a tool to assess the risk of PU. The study aimed to identify changes in the score of the Braden subscales are associated with the risk of developing PCU. Logistic regression was used in a retrospective cohort study conducted in Hospital de Clínicas de Porto Alegre in adults hospitalized in surgical clinical units from October 2005 to June 2006. We evaluated the records database of 1503 patients with a mean aged 55.5 +/- 16 years, 52.7% female. The incidence of PU was 1.8% and was associated with diabetes and heart failure. There was a higher PU in patients worst in sensory perception, mobility, and activity and the presence of moisture. No association was found between nutrition and PU. Except nutrition, the other Braden sub-scales shown to be predictive of PU.

Enhancement of decision rules to increase generalizability and performance of the rule-based system assessing risk for pressure ulcer

BACKGROUND

A rule-based system, the Braden Scale based Automated Risk Assessment Tool (BART), was developed to assess risk for pressure ulcer in a previous study. However, the BART illustrated two major areas in need of improvement, which were: 1) the enhancement of decision rules and 2) validation of generalizability to increase performance of BART.

OBJECTIVES

To enhance decision rules and validate generalizability of the enhanced BART.

METHOD

Two layers of decision rule enhancement were performed: 1) finding additional data items with the experts and 2) validating logics of decision rules utilizing a guideline modeling language. To refine the decision rules of the BART further, a survey study was conducted to ascertain the operational level of patient status description of the Braden Scale. The enhanced BART (BART2) was designed to assess levels of pressure ulcer risk of patients (N = 99) whose data were collected by the nurses. The patients' level of pressure ulcer risk was assessed by the nurses using a Braden Scale, by an expert using a Braden Scale, and by the automatic BART2 electronic risk assessment. SPSS statistical software version 20 (IBM, 2011) was used to test the agreement between the three different risk assessments performed on each patient.

RESULTS

The level of agreement between the BART2 and the expert pressure ulcer assessments was "very good (0.83)". The sensitivity and the specificity of the BART2 were 86.8% and 90.3% respectively.

CONCLUSION

This study illustrated successful enhancement of decision rules and increased generalizability and performance of the BART2. Although the BART2 showed a "very good" level of agreement (kappa = 0.83) with an expert, the data reveal a need to improve the moisture parameter of the Braden Scale. Once the moisture parameter has been improved, BART2 will improve the quality of care, while accurately identifying the patients at risk for pressure ulcers.