The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problem

Incidence of pressure injuries in fracture patients: A systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the incidence of pressure injuries (PIs) in hospitalized fracture patients and to provide evidence for the prevention and treatment of PIs.

METHODS

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Electronic databases including PubMed, Embase, the Cochrane Library, Web of Science, CINAHL, China Knowledge Resource Integrated Database (CNKI), WanFang Database, Weipu Database (VIP), and Chinese Biomedical Database (CBM) were searched to collect cross-sectional studies and cohort studies related to PIs among hospitalized fracture patients. All electronic literature sources were searched from inception to March 2022, and a hand-search through references was also conducted to find relevant articles. Studies were evaluated independently by two researchers and audited by a third researcher. The data were extracted and presented in tables. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. All data analysis used Stata14.0. The I² statistic and random-effects model were used to determine the heterogeneity.

RESULTS

A total of 7906 articles were screened, and 18 studies with 8956 patients were ultimately involved in this review. The pooled incidence of PIs in the fracture patients was 20.4% (95%CI: 14.9 to 25.8), and the incidence of PIs only in spinal and hip fracture patients was 23.9% (95%CI: 19.6 to 28.2). The incidence of PIs in 65 years old or over was significantly high (23.3% [95%CI: 15.3 to 31.2]). The most affected body sites were sacrococcygeal regions (56.7%) and heels (19.9%). The most common stages were stage 2 (62.2%) and stage 1 (17.4%).

CONCLUSION

The overall incidence of PIs in fracture patients was as high as 20.4%, significantly higher than the average incidence of adults. We found that the potential for PIs in fracture patients increases with age. Hence, our discoveries recommended that healthcare givers should consider reducing the occurrence of PIs. Additionally, more research may be conducted to improve the understanding of characteristics of PIs among fracture patients and to identify PIs risk factors to prevent and treat them effectively.

The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review

The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review (PubMed including PubMed, PubMed Central and Medline; PDQ Evidence; Web of Science Core Collection; CINHAL). To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages (title, abstract, full text) and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.

Diabetes and pressure ulcer risk in hip fracture patients: a meta-analysis

OBJECTIVE

The aim of this study was to assess the relationship between diabetes and pressure ulcer (PU) risk in patients with hip fractures.

METHOD

Searches of MEDLINE (1966-), ISI Databases (1965-) and Scopus (1996-) were performed for English language studies. The search data was 29 July 2016. Odds ratio (OR) for PUs were calculated for hip fracture patients with or without diabetes and a meta-analysis was carried out following meta-analysis of observational studies in epidemiology (MOOSE) guidelines.

RESULTS

A total of 8 studies with 22,180 patients were included in this study. The mean PU incidence was 15.1% in group with diabetes compared with 7.5% in the group without diabetes. When comparing with and without diabetes meta-analysis showed the summary OR was 1.825 [95% confidence interval (CI): 1.373-2.425; z=4.15, p<0.00001]. No significant publication bias was found. Sensitivity analysis included prospective studies [OR: 1.383, 95%CI: 1.035-1.847] and pooled the adjusted OR [OR: 1.282, 95%CI: 1.054-1.560] showed the result was robust. Subgroup analysis by PU stage showed the summary OR was 1.474 [95% CI 0.984-2.207] for ≥ category II PU, and 2.814 [95%CI: 2.115-3.742] for ≥category I PU. The meta-regression showed PU incidence explained 27.77% proportion of between-study variance, but statistical test showed no significance (t=-1.96, p=0.097).

CONCLUSION

Our meta-analysis indicates that diabetes increases the PU risk in hip fracture patients. Therefore, specific recommendations should apply for the management of diabetic patients with hip fractures at risk of PU.

Association of Temporal Variations in Staffing With Hospital-Acquired Pressure Injury in Military Hospitals

To more precisely evaluate the effects of nurse staffing on hospital-acquired pressure injury (HAPI) development, data on nursing care hours per patient day (NCHPPD), nursing skill mix, patient turnover (i.e., admissions, transfers, and discharges), and patient acuity were merged with patient information from pressure injury prevalence surveys that were collected annually for the Military Nursing Outcomes Database (MilNOD) project. The MilNOD included staffing and adverse events from 56 medical-surgical, stepdown, and critical care units in 13 military hospitals over a 4-year-period. Data on 1,643 patients were analyzed with Cox proportional hazards models and generalized estimating equations. Staffing was not associated with pressure injuries in stepdown or critical care patients. However, among the 1,104 medical-surgical patients, higher licensed practical nurse (LPN) nursing care hours per patient day (NCHPPD) 3 days and 1 week prior to the HAPI discovery date were associated with fewer HAPI (HR 0.27, p < .001), after controlling for patient age, Braden mobility score, and albumin level. Neither total staff number, nor RN NCHPPD, nor the proportion of staff who were RNs (RN skill mix) were associated with HAPI. These findings suggest that on military medical-surgical units, LPNs play a major role in HAPI prevention. Although the national trend in acute care is to staff hospital units with more RNs and patient care technicians, and fewer LPNs, hospitals should reconsider LPNs as valuable members of the nursing care team. © 2016 Wiley Periodicals, Inc.

Characteristics of patients who are admitted with or acquire Pressure Ulcers in a District General Hospital; a 3 year retrospective analysis

Aim

The study aimed to characterize demographic and clinical practice factors associated with community (CAPU) and hospital acquired pressure ulcers (HAPU).

Design

A comparative retrospective evaluation of pressure ulcer data, collected from a district general hospital.

Methods

Demographic and pressure ulcer related data were collected from patients at risk of developing a pressure ulcer, collated by a single observer using a standardized tool. Comparisons were made within and between patient groups (no PU, CAPU and HAPU).

Results

CAPU and HAPU patient groups were significantly (P < 0·001) older, had extended lengths of hospital stay and were less likely to be provided quickly with a pressure relieving support surface than those with no PU. HAPU patients had a longer length of stay and a higher proportion of heel PUs compared to CAPU.

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.

A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I)

OBJECTIVE

To provide a critical appraisal and synthesis of the published literature pertaining to pressure ulcer (PU) prevalence, incidence and prevention practices from the context of Scandinavia, Iceland and Ireland.

METHOD

An integrative research review following Cooper's five stages. Studies published in peer-reviewed journals, involving any study design, but specifically exploring PU prevalence or incidence in adults or children, in any care setting, were included.

RESULTS

Fifty-five papers were data extracted, quality appraised and included in the qualitative synthesis of the review. Mean prevalence in Norway was 17% (4.8-29%) in Ireland was 16% (4-37%), in Denmark was 15% (2.2-35.5%) and in Sweden was 25%, (0.04-42.7%). Prevalence in Iceland was 8.9%. In acute care, mean prevalence was 21% (0-42.7%) and in long stay was 12% (2.4-23.7%). Prevalence among hospice patients was 35.7%, and in community care was 0.04% and 4%. No incidence study from Iceland was identified; the single incidence study from Norway noted a figure of 16.4%. The mean incidence from Ireland was 11% (8-14.4%) from Sweden was 20% (3.1-49%) and Denmark was 1.8% (1.4-2.7%). Mean incidence in acute care setting was 17.6%, (1.4-49%); in long stay was 6.63% (3.1-8.4%). Incidence in the hospice setting was 20.4%. No study reported PU incidence figures from the community setting.

CONCLUSION

Figures for both prevalence and incidence were similar in Ireland and Norway and highest in Sweden, whereas Denmark demonstrated the lowest incidence rates and Iceland demonstrated the lowest prevalence rates. Figures were consistently highest in acute care and hospice settings, and lowest in the care of the older person setting.

A review of PU risk assessment and prevention in Scandinavia, Iceland and Ireland (part II)

OBJECTIVE

To provide a critical appraisal of nurses risk assessment and pressure ulcer (PU) preventive practices across Scandinavia, Iceland and Ireland.

METHOD

An integrative research review following Cooper's five stages. Studies published in peer-reviewed journals, involving any study design, but specifically exploring PU risk assessment or preventative practices, in any care setting, were included.

RESULTS

Risk assessment practice was primarily investigated in the acute care setting and was found to be irregular, based on both numeric scales and clinical judgments. This irregular practice means that some vulnerable patients are not screened for pressure ulcer risk, conversely, when risk assessed, a care plan is not necessarily provided.A significant gap in nurse documentation, together with a lack of supporting evidence for repositioning and use of appropriate redistribution devices was also identified,indicating a lack of a standardised approach to pressure ulcer prevention.

CONCLUSION

Despite an abundance of literature exploring this subject, it is clear that current practice in pressure ulcer prevention is not embedded within best practice recommendations. Therefore, to address the potential patient safety implications, clinical practice could benefit from exploration and identification of practical methods for improving actual pressure ulcer preventive practice.

Perioperative implications of surgery in elderly patients with hip fractures: an evidence-based review

Hip fracture is a major cause of morbidity, mortality and loss of independence for the elderly. Surgical fixation of the fractured hip remains the standard of care to allow for early mobilisation and a return to independence. Operative management in this population carries its own set of problems. The altered physiological state of the older person, often coupled with significant comorbidity, can present challenges for the anaesthetist, the surgeon and the rest of the perioperative team. This article provides an evidence-based review of the important perioperative factors associated with hip fractures in the older person and their management.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

AIMS

This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.

INTRODUCTION

Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.

DATA SOURCES

Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.

REVIEW METHODS

A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.

RESULTS

Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.

CONCLUSION

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

Factors of importance to the development of pressure ulcers in the care trajectory: perceptions of hospital and community care nurses

AIM

The study aimed at describing contributing factors for the progression or regression of pressure ulcers in the care trajectory as they were understood by nurses working in hospitals or community care.

BACKGROUND

The development of pressure ulcers is considered to be connected with early prevention and awareness among nurses and some studies have indicated that the care trajectory may be a weak point.

DESIGN

The study was carried out with a qualitative design.

METHOD

Fifteen nurses from two Swedish hospitals and 15 nurses from community care were interviewed during 2005. Qualitative content analysis was used to make an understanding of patterns possible.

FINDINGS

Three main categories arose, showing that pressure ulcers were considered to be affected in the care trajectory by factors related to the individual patient, to the healthcare personnel and to the healthcare structure. Hospital and community care nurses mostly had corresponding perceptions of these factors.

CONCLUSION

The study both confirmed previous findings and added new knowledge about factors that may affect pressure ulcer in the trajectory of care. The informants' views of nurses' responsibilities and their attitudes towards the care of pressure ulcers could, along with their views on the organisation of care, increase the understanding of the occurrence of pressure ulcers. The need for development and clarification of the organisation and responsibility of pressure ulcer care in the care trajectory was stressed. Relevance to clinical practice. The study highlighted attitudes and values among registered nurses, as well as to how to preserve their commitment and increase their knowledge concerning prevention of pressure ulcers.

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

AIMS

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

BACKGROUND

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

DESIGN

The study was conducted as a descriptive and prospective study.

METHOD

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk factors

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

Pressure ulcer prevention and management strategies in Turkey

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

Pressure Ulcers Among Elderly Patients Early in the Hospital Stay

BACKGROUND

Pressure ulcers among elderly hospital patients diminish quality of life and increase the cost of hospital care. Evidence suggests that pressure ulcers can arise after only a few hours of immobility. The goals of this study were to estimate the incidence of hospital-acquired pressure ulcers in the first 2 days of the hospital stay and to identify patient characteristics associated with higher incidence.

METHODS

A prospective cohort study was performed between 1998 and 2001. A total of 3233 patients 65 years old or older admitted through the Emergency Department to the inpatient Medical Service at two study hospitals were examined by a research nurse on the third day of hospitalization. Pressure ulcers were ascertained using standard criteria and were classified as either preexisting, possibly hospital-acquired, or definitely hospital-acquired.

RESULTS

There were 201 patients with one or more possibly or definitely hospital-acquired pressure ulcers for a cumulative incidence of 6.2% (95% confidence interval, 5.4%-7.1%). Most of the pressure ulcers were stage 2, and the majority were in the sacral area or on the heels. In multivariable analysis, pressure ulcer incidence was significantly associated with increasing age, male gender, dry skin, urinary and fecal incontinence, difficulty turning in bed, nursing home residence prior to admission, recent hospitalization, and poor nutritional status.

CONCLUSIONS

A small but significant proportion of elderly emergently admitted hospital patients acquire pressure ulcers soon after their admission. New models of care may be required to ensure that preventive interventions are provided very early in the elderly person's hospital stay.

Risk, prevalence and prevention of pressure ulcers in three Swedish healthcare settings

OBJECTIVE

This cross-sectional survey set out to delineate risk, prevalence and prevention of pressure ulcers in a university hospital, a general hospital and a nursing home in Sweden. It also looked at the differences in risk factors and preventive strategies between patients with and without pressure ulcers.

METHOD

The one-day survey followed the methodology developed by the European Pressure Ulcer Advisory Panel (EPUAP). It was conducted on Tuesday 5 February 2002. Each patient was visited by two registered nurses, their skin was inspected and any pressure ulcer classified according to the EPUAP grading system. A total of 695 patients were included: 612 from the university hospital, 38 from the general hospital and 45 from the nursing home.

RESULTS

The prevalence of pressure ulcers was 23.9% (university hospital), 13.2% (general hospital) and 20.0% (nursing home). Most (60-66%) of the pressure ulcers in the hospitals were assessed as grade I. Only half of the patients at risk or with pressure ulcers were placed on a pressure-reducing mattress and a third of these patients had a plan for repositioning. Significant variables associated with pressure ulcers were old age, geriatric care, low Braden score and incontinence.

CONCLUSION

Prevalence of pressure ulcers was higher than expected. Results relating to both prevalence of pressure ulcers (grade I excluded) and the preventive care given to patients at risk or with pressure ulcers accord with those of a larger Dutch study. Attention must focus on the appropriate risk-assessment skills, highlighting grade I as pressure damage, and the use of appropriate preventive strategies, based on the level of risk.

Reliability of pressure ulcer classification and diagnosis

AIM

To assess the inter-rater reliability of the PRESSURE Trial pressure ulcer diagnosis (>/=Grade 2) and skin classification for all grades between the clinical research nurse (CRN) team leader and CRNs working across different hospital sites; and CRNs and ward-based nurses.

BACKGROUND

The United Kingdom National Health Service Health Technology Assessment Programme has funded a multi-centre, randomized controlled trial to compare the clinical and cost-effectiveness of alternating pressure mattress overlays and mattress replacements - PRESSURE Trial. Outcome skin assessments were recorded by qualified ward-based nurses daily, and expert CRNs twice weekly.

METHOD

Paired assessments were undertaken and skin assessed on seven body sites. The per cent agreement between nurses in the diagnosis of a pressure ulcer was determined and the Kappa statistic and confidence intervals calculated. Per cent agreement between nurses in classifying skin for all grades was also determined.

RESULTS

Assessments were undertaken by 378 pairs: 16 paired patient assessments (107 site comparisons) by the CRN team leader and CRNs, and 362 paired patient assessments (2396 site comparisons) between CRNs and ward-based nurses. There was 100% agreement between the CRN team leader and CRNs in the diagnosis of a pressure ulcer, and the Kappa statistics indicated 'very good' agreement. There were only two (1.9%) disagreements in classifying skin for all grades between these nurses. The agreement in the diagnosis of a pressure ulcer between CRNs and ward-based nurses varied by skin site, ranging from 93.6% to 100%, with the Kappa statistics indicating 'good' and 'very good' agreement. However, there were 508 (21.2%) disagreements in classifying skin for all grades.

CONCLUSIONS

Overall agreement and Kappa statistics indicated 'very good' and 'good' agreement between expert nurses, and between expert nurses and qualified ward-based staff, respectively. However, the high prevalence of normal skin concealed clinically important disagreements in both the diagnosis of pressure ulcers and skin classification for all grades.

Accuracy and Quality in the Nursing Documentation of Pressure Ulcers

OBJECTIVE

To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting.

DESIGN

A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients.

SETTING AND SUBJECTS

All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital.

INSTRUMENTS

The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation.

METHODS

All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments.

RESULTS

The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor.

CONCLUSIONS

Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.

Reduction of nosocomial pressure ulcers in patients with hip fractures: a quality improvement program

Pressure ulcers (PUs) continue to be a distressing medical problem. The Nursing Quality Improvement Unit of Israel's Hadassah Mount Scopus Medical Center designed and implemented a quality improvement intervention program to reduce the incidence of nosocomial PUs. Assessing data, it was found that 46.7 percent of nosocomial PUs develop inpatients with hip fractures. Following the first audit of all patients with hip fractures, an intervention program was focused on the orthopedic ward and the recovery room. Intervention in the orthopedic ward included providing each patient with a visco-elastic mattress and a specially designed cushion for the elevation of the affected limb. In the recovery room, pressure-relieving practices were introduced. Following the implementation of the intervention program, the second audit revealed a reduction in the incidence of nosocomial PUs from 12.9 percent to 0 percent. Although patients with hip fractures are still at very high risk of developing nosocomial PUs, prevention is feasible.

Changing the system: a quality management approach to pressure injuries

The quality management (QM) department at a large integrated healthcare system developed a methodology for preventing, predicting, and treating pressure injuries across the continuum, from acute care to long-term care to home care. The initiative, the first recipient of the Ernest A. Codman Award of the Joint Commission on Accreditation of Healthcare Organizations in the network category, resulted in decreased incidence and severity of pressure injuries, reduced length of stay, and significant cost savings to the system. The process the department used illustrates how an innovative QM program can facilitate change and institute a uniform standard of care.

Debating the relative unimportance of pressure-reducing equipment

This article examines some assumptions underlying the provision of pressure-reducing equipment, and argues that failure to 'act first and ask questions later' may be a key source of pressure damage. Indeed, it is argued that prevention of pressure damage can be simplified by identifying three groups of patients: those who have pressure ulcers; those who will develop them in faction is not taken; and those who will not get them. The linkage of risk assessment scores and guidelines is challenge as erroneous and misleading.