Risk factors for pressure ulcers in acute care hospitals

Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure Ulcers

Introduction

A hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana).

Methods

A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug-Oct 2021).

Results

Development of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period.

Conclusion

This study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.

Sacral Ulcer Development Risk Among Older Adult Patients in North Texas Rehabilitation Hospitals: Role of Comorbidities, Lifestyle, and Personal Factors

PURPOSE

Sacral ulcers are a serious mortality risk for older adults; thus, we aimed to determine sacral ulcer risk factors among older adults who were recently admitted to rehabilitation hospitals.

METHOD

We conducted a retrospective cohort study using the Texas Inpatient Discharge database (2021). The study included 1,290 rehabilitation hospital patients aged ≥60 years diagnosed with sacral ulcers. The control group comprised 37,626 rehabilitation hospital patients aged ≥60 years without sacral ulcers. Binary logistic regression was used to identify risks for sacral ulcer development adjusting for patient demographics, insurance type, and lifestyle.

RESULTS

Comorbidities of dementia, Parkinson's disease, type 2 diabetes, and cardiac dysrhythmias were significantly associated with increased risk of sacral ulcers. Longer length of stay, Medicare, and Medicare HMO were also associated with sacral ulcers. Demographically, older age, male sex, identifying as African American, and having malnutrition all had a 50% increased prevalence of sacral ulcers.

CONCLUSION

Findings indicate a need to proactively treat chronic comorbidities in vulnerable populations to reduce their possible risk for hospital-acquired infections and excess mortality from sacral ulcers. [Journal of Gerontological Nursing, 50(2), 32-41.].

Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes

BACKGROUND

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery.

METHODS

A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System.

RESULTS

Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition.

CONCLUSION

The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

Pressure Ulcer Diagnosis Is Associated with Increased Mortality in Patients with End-Stage Renal Disease: A Retrospective Study

Pressure ulcers are associated with multiple comorbidities and annually affect approximately 3 million Americans, directly accounting for approximately 60,000 deaths per year. Because patients with end-stage renal disease (ESRD) are known to present with unique factors which impair wound healing, pressure ulcers diagnosed in ESRD patients might independently increase the risk of mortality. To investigate the association between pressure ulcer diagnosis and mortality risk in the ESRD population, a retrospective analysis of the United States Renal Data System (USRDS) database was performed. The records of 1,526,366 dialysis patients who began therapy between 1 January 2005 and 31 December 2018 were included. Our analysis showed that the diagnosis of pressure ulcers in this population was independently associated with mortality even after controlling for confounding factors (p < 0.001). A Kaplan-Meier survival analysis demonstrated reduced survival in patients with a pressure ulcer diagnosis compared to those without a pressure ulcer diagnosis. These results establish pressure ulcers as a significant independent risk factor for mortality, as well as suggesting several comorbidities as potential risk factors for pressure ulcers in the ESRD population.

Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care

GENERAL PURPOSE

To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Efficacy and Safety of Topical Application of Olive Oil for Preventing Pressure Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The purpose was to identify and summarize the existing evidence on the efficacy and safety of the topical application of olive oil for preventing pressure ulcers (PUs). We included only randomized controlled trials (RCTs) involving patients at risk of developing PUs, testing the topical application of olive oil versus other products for PU prevention. We assessed the risk of bias using the RoB 2 tool, and the certainty of the evidence with GRADE. Four RCTs met the eligibility criteria. All studies were judged at a low risk of bias overall. The meta-analysis showed that the clinical efficacy of olive oil for prevention occurs by reducing the incidence of PUs (RR = 0.56, 95% CI = 0.30 to 0.79, I² = 0%); with no differences in adverse effects, it may be associated with a shorter development time of PUs and shorter hospital stays. The certainty of the evidence assessed by the GRADE approach was moderate and low. The topical application of olive oil is effective and safe in reducing the incidence of PUs compared to other treatments. These findings could provide new insights into olive oil as a preventive and alternative treatment for PUs as it is accessible and inexpensive compared to other products.

Incidence and prevalence of pressure ulcers in hospitals: 10-year cohort study

OBJECTIVE

Pressure ulcers (PUs) are a serious problem in patients with multiple comorbidities and are associated with a longer duration of hospital stay and higher medical costs. The aetiology and rate of PU occurrence in South Korea remains unclear. Therefore, we aimed to determine the incidence, prevalence, mortality and common comorbidities of hospitalised patients with PUs in the South Korean healthcare system.

METHOD

A 10-year cohort study using the healthcare insurance reimbursement claims from the South Korean National Health Insurance System database. Patients diagnosed with a PU on admission to hospital [ICD-10: L89 + procedure code] between January 2002 and December 2016 were included and their comorbidities evaluated. Patients <20 years of age and recurrent PU cases were excluded.

RESULTS

Incidence, prevalence, survival rate and risk factors related to survival rate of patients with PUs were determined. The study population in 2006 was 36,195,121 (all patients admitted to hospital that year), which changed yearly because of the inclusion of additional patients who met the study inclusion criteria, and removal of patients who had died during the year. Standardised PU incidence rate decreased from 17.1 in 2006 to 14.9 in 2015 per 10,000 people. Standardised PU prevalence also showed a slightly decreasing trend from 20.2 in 2006 to 18.9 in 2015 per 10,000 people.

CONCLUSION

This findings of this 10-year study showed that incidence and prevalence of PUs markedly increased with age after the seventh decade. Incidence of PUs increased in patients with pneumonia, cerebral infarction, sepsis, femoral neck fracture and malignant neoplasm of the bronchus. Patients with femoral neck fracture and cerebral infarction showed a higher rate of survival than those with other high-risk comorbidities.

Investigation of the effect of a 15-degree tilt-in-space on the fluctuation of shear forces exerted on the buttocks when the back support is reclined

[Purpose] This study aimed to investigate the effect of the combination of 15° tilt-in-space and recline angles on the fluctuation of shear forces exerted on the buttocks. [Participants and Methods] The participants were 11 healthy adult males. The parameters of the shear forces were the parallel and perpendicular forces exerted on the buttocks as measured by a force plate. The two conditions tested were T0R100-130 and T15R100-130. The tilt-in-space angles were set to 0° and 15° in the T0R100-130 and T15R100-130 conditions, respectively. The reclining angles were determined to be 100° to 130° in both conditions. [Results] Upon comparing the two conditions, the parallel and the perpendicular forces exerted on the buttocks in the T15R100-130 condition were significantly lower than those in the T0R100-130 condition in all positions of back support. Upon comparing the fluctuation values of the parallel and perpendicular forces, those applied in the T15R100-130 condition were significantly higher than those in the T0R100-130 condition. [Conclusion] These results suggest that the fluctuation of shear forces exerted on the buttocks could be decreased by using a combination of 15° tilt-in-space and reclining functions.

The 5-Factor Modified Frailty Index as a Predictor of 30-day Complications in Pressure Ulcer Repair

BACKGROUND

The 5-item modified frailty index (mFI-5) is a validated tool to assess postoperative risks in older surgical candidates. We sought to compare the predictive ability of mFI-5 to its individual components and other established risk factors for complications in flap reconstruction of late-stage pressure ulcer repair.

METHODS

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for pressure ulcer diagnosis and reconstructive flap repair procedures. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status before surgery, diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, and history of hypertension requiring medicine), and other factors commonly used to risk-stratify (age, obesity, ASA classification, and history of smoking) were associated with complications.

RESULTS

35.1% of the total 1254 flap reconstructive procedures for pressure ulcer repair experienced complications. Most cases had at least one of the five mFI-5 factors in both the complication (42.7%) and no complication (45.7%) cohorts. Compared with the factors making up the mFI-5 score and other common variables used to risk-stratify, mFI-5 was significantly associated with complications in the univariate (OR 1.17, CI 1.03 - 1.33; P = 0.02) and multivariate analysis (OR 1.16, CI 1.02 - 1.34; P = 0.043).

CONCLUSIONS

The mFI-5 is a useful predictor of postoperative outcomes in patients undergoing reconstructive flap surgery for pressure ulcer injuries compared to other historically considered risk factors for surgical complications.

Adverse Events in Home-Care Nursing Agencies and Related Factors: A Nationwide Survey in Japan

Despite the importance of patient safety in home-care nursing provided by licensed nurses in patients’ homes, little is known about the nationwide incidence of adverse events in Japan. This article describes the incidence of adverse events among home-care nursing agencies in Japan and investigates the characteristics of agencies that were associated with adverse events. A cross-sectional nationwide self-administrative questionnaire survey was conducted in March 2020. The questionnaire included the number of adverse event occurrences in three months, the process of care for patient safety, and other agency characteristics. Of 9979 agencies, 580 questionnaires were returned and 400 were included in the analysis. The number of adverse events in each agency ranged from 0 to 47, and 26.5% of the agencies did not report any adverse event cases. The median occurrence of adverse events was three. In total, 1937 adverse events occurred over three months, of which pressure ulcers were the most frequent (80.5%). Adjusting for the number of patients in a month, the percentage of patients with care-need level 3 or higher was statistically significant. Adverse events occurring in home-care nursing agencies were rare and varied widely across agencies. The patients’ higher care-need levels affected the higher number of adverse events in home-care nursing agencies.

Surgical treatment of pressure ulcer: various flaps and other surgical methods

Pressure ulcers remain a common health problem, particularly among physically limited or bedridden older adults, and they can cause significant morbidity and mortality. Conservative management is ineffective for stage III or IV pressure ulcers, and surgery to create flap coverage becomes inevitable. Basic surgical principles for the treatment of pressure ulcers include complete excision of the ulcer, surrounding scar, underlying bursa, and soft tissue calcification; radical removal of underlying bone and any heterotropic ossification; padding of bone stumps and filling dead space; resurfacing with large regional pedicled flaps; and grafting the donor site of the flap, if necessary. For effective edge resection, all the flaps should be designed to be as large as possible, placing the suture line away from the area of direct pressure, and the flap design should also not violate adjacent flap territories to preserve all options for coverage if a breakdown or recurrence dictates further reconstruction. There are surgical methods for stage III or IV wide range pressure ulcers: reconstruction surgery using a skin flap, muscle flap, fascia-skin flap, or free flap. The skin graft is not generally recommended as a surgical procedure for stage III or IV pressure ulcers because it cannot provide enough strength to cover the wound. This review presents various surgical treatments of pressure ulcers including muscle, musculocutaneous, perforator-based, and free flap.

Implementation of pressure ulcer prevention and management in elderly patients: a retrospective study in tertiary care hospital in Qatar

OBJECTIVE

Preventing pressure ulcers is an essential part of patient care and it is important to be aware of the best way to prevent it. Hence, the present study aims to look for the demographics, clinical characteristics, and risk factors in patients with and without pressure ulcer among elderly patients.

METHODS

A retrospective longitudinal study was conducted in elderly (above 65 years) patients from a period of October 2014 to October 2015 in the medical ward under acute Geriatric care at Hamad General Hospital in Qatar.

RESULTS

Overall, a total of 90 patients were included with an average age of 79 ± SD 11.3 years of which 45 patients developed pressure ulcer. There was male (64.4%) preponderance in the study population. Most common comorbidity was hypertension (77.8%). Anemia correction (91%), high protein diet supplementation (1.5 g/kg body wt.) (100%), and 2 h repositioning (100%) were implemented for majority of the pressure ulcer patients as preventive intervention.

CONCLUSIONS

From the study finding, it is observed that, anemia correction, high protein diet supplementation and 2 h repositioning are the best practices for the management of pressure ulcer. Hence, these best practices are recommended for the early prevention of pressure ulcer among elderly.

Pressure Ulcer Risk Factors in Persons with Mobility-Related Disabilities

OBJECTIVE

To assess pressure ulcer (PU) risk in persons with mobility impairments using a large data set to identify demographic, laboratory, hemodynamic, and pharmacologic risk factors.

METHODS

The cohort of interest was persons with disabilities who have mobility impairments and are diagnostically at risk of PUs. To define this cohort, diagnoses that qualify patients for skin protection wheelchair cushions were used. Data were obtained from the Cerner Health Facts data warehouse. Two cohorts were defined: persons with and without a history of PUs. Analysis included descriptive statistics and multivariate logistic regression modeling. Variables retained in the model were identified using LASSO, gradient boosting, and Bayesian model averaging.

MAIN RESULTS

The resulting cohorts included more than 87,000 persons with a history of PUs and more than 1.1 million persons who did not have a PU. The data revealed seven disability groups with the greatest prevalence of PUs: those with Alzheimer disease, cerebral palsy, hemiplegia, multiple sclerosis, paraplegia/quadriplegia, Parkinson disease, and spina bifida. Ulcers in the pelvic region accounted for 82% of PUs. Persons with disabilities who were male or black had a greater prevalence of PUs. Physiologic risk factors included the presence of kidney or renal disease, decreased serum albumin, and increased serum C-reactive protein.

CONCLUSIONS

The results indicate that, although persons with disabilities can exhibit a wide functional range, they remain at risk of PUs and should be evaluated for proper preventive measures, including support surfaces and wheelchair cushions.

Pressure Injury Prevention Considerations for Older Adults

There are well-documented physiologic changes that occur in the human body during the aging process, such as decreased body fat, decreased muscle mass, cellular senescence, changes in skin pH, decreased metabolism, decreased immune function, vascular changes, altered tissue perfusion, nutritional status changes, and poor hydration. These changes affect skin integrity and wound healing, and raise the risk of pressure-related skin injury. This article discusses aging as a risk factor for pressure injury (PrI). Topics include evidence for advancing age as a significant PrI risk factor, identifying pathophysiologic changes/mechanisms of aging, and specific PrI preventive interventions to consider in older adults.

Prevention and treatment of pressure sore following spinal cord injury

Pressure sores or pressure injury is a serious complication of a spinal cord injury (SCI), representing a challenging problem for patients, their caregivers, and their physicians. Persons with SCI are vulnerable to pressure sores throughout their life. Pressure sores can potentially interfere with the physical, psychosocial, and overall quality of life. Outcomes directly depend on education and prevention along with conservative and surgical management. Therefore, it is very important to understand everything about pressure sores following SCI. This review covers epidemiology, cost, pathophysiology, risk factors, staging, evaluation tools, prevention, education, conservative wound care methods, surgical treatment, and future trends in wound healing related to post-SCI pressure sores. A change in nomenclature was adopted by the National Pressure Ulcer Advisory Panel in 2016, replacing “pressure ulcer”with “pressure injury.” New concepts of pressure injury staging, such as suspected deep tissue injuries and unstageable pressure injuries, were also introduced. A systematic evidence-based review of the prevention of and therapeutic interventions for pressure sores was also discussed.

An investigation into the effectiveness of a novel wheelchair seat-cover assembly for the reduction of forces exerted onto the buttocks

Purpose: This purpose was to investigate developed seat-cover assemblies' effect on decreasing the fluctuation of the shear force exerted onto the buttocks as the factors causing decubitus ulcers when the back-support was inclined.Materials and Methods: The participants were 10 wheelchair users. The force plate was used to measure the horizontal force as the shear force. The back-support was inclined at increasing angles, starting from the upright position (IUP), then proceeding to a fully reclined position (FRP), and returning to the upright position (RUP). The experimental conditions were two conditions; the seat-cover assembly conditions and without the seat-cover assembly as the control conditions.Results: The average values in the seat-cover assembly condition were 14.4 ± 3.3, 13.9 ± 2.3, and 17.3 ± 3.3% body weight in the IUP, FRP, and RUP, respectively. The average values in the control condition were 14.8 ± 2.6, 11.4 ± 1.7, and 24.0 ± 6.7% body weight in the IUP, FRP, and RUP, respectively. In the FUP and the RUP, there were significant differences between two conditions (p < .01).Conclusion: These results suggested that the shear force exerted onto the buttocks may to be decreased by using novel seat-cover assembly.Implications for rehabilitationIt is possible to decrease the fluctuations in the shear force by moving the body up and down according the novel seat-cover assembly attached the back-support incline.Disabled, older individuals can be provided with a comfortable life on a reclining wheelchair while preventing decubitus ulcers.

Practice on pressure ulcer prevention among nurses in selected public hospitals, Tigray, Ethiopia

Objectives

Pressure ulcers are localized cellular damages to the skin and underlying tissues caused by pressure, shearing and frictional force. The aim of this study is to assess practices towards pressure ulcer prevention among nurses in the Central Zone of Tigray, Ethiopia, from September 10, 2017 to June 15, 2018. This study has also identified the major barriers that hamper nurses from preventing pressure ulcers. These barriers were heavy workload, inadequate training, and lack of universal guideline and shortage of resource. 17.2% of the participants had a good practice and 82.2% of the respondents had a poor practice of pressure ulcer prevention.

Result

Finding of this study showed that respondents have inadequate knowledge which may have led to their poor practice towards pressure ulcer prevention. Immediate intervention should be done on public hospitals of central Tigray to improve nurses’ practice towards pressure ulcer prevention.

Predictive factors for category II pressure ulcers in older patients with hip fractures: a prospective study

OBJECTIVE

To identify the incidence of category II or higher hospital-acquired pressure ulcers (HAPU) and significantly associated factors in older patients with hip fractures. PUs are a frequent complication in hip fracture patients, negatively impacting patients' quality of life, the health-care system and society.

METHOD

A prospective cohort study was conducted. A consecutive sample of patients with pertrochanteric, femoral neck or subtrochanteric fractures requiring surgical treatment, were included. A stepwise, multiple regression was performed to identify factors associated with PU development.

RESULTS

A total of 761 patients aged ≥65 years were sampled. The incidence of category II or higher PUs was 12%. The study identified five factors that were significantly, independently associated with category II or higher PU development, including a higher preoperative Braden score (Hazard Ratio [HR]: 0.884; 95% confidence interval [CI]: 0.806-0.969), surgical procedure with osteosynthesis (HR 1.876; 95%CI: 1.183-2.975), a higher percentage of days with the presence of foam valve before surgery (HR: 1.010; 95%CI: 1.010-1.023) and a urinary catheter (HR: 1.013; 95%CI: 1.006-1.019) and diaper (HR: 1.007; 95% CI 1.001-1.013) in the postoperative period.

CONCLUSION

Attention should be given by clinical staff to avoiding the use of foam valves, to limiting the use of diapers and to early removal of urinary catheters.

Care under the guidance of pressure injury prevention protocol: a nursing home sample

Pressure injury is a healthcare problem frequently encountered in nursing homes. This study evaluated the effects of the care delivered under the guidance of a protocol for pressure injury prevention at a nursing home. It was implemented in four phases. In the pre-protocol period, the pressure injury incidence and nurses' care practices were evaluated. In the second phase, nurses were trained to use the protocol. In the third phase, the nurses provided care under the guidance of the protocol (post-protocol period). In the fourth phase, the incidence of pressure injury and nurses' care practices were compared between the pre- and post-protocol periods. The average age of the older residents was 78.40±7.12 years, and all were at high or very high risk of pressure injury according to the Braden scale scores. Some 30% were bed bound; 90% had faecal and urinary incontinence; and 70% had malnutrition. The results showed that the pressure injury incidence reduced from 17.39% in the pre-protocol period to 10.87% in the post-protocol period, while the nurses' care practices improved in the post-protocol period. Thus, use of pressure injury-prevention protocols can reduce the incidence of these injuries in vulnerable care home residents.

Hypotension at emergency department admission and hospital-acquired pressure ulcers in older patients: prospective study

OBJECTIVE

To investigate the relationship between admission hypotension and hospital acquired pressure ulcers (PU) among older patients in an emergency department.

METHODS

The study was a prospective cohort conducted between March and May 2017 in the emergency department of a tertiary care hospital in Eastern China. Data on PUs and possible PU risk factors were collected using a pre-designed form. Multivariate logistic regression was used to calculate the adjusted odds ratio (OR).

RESULTS

A total of 157 older patients were included in the study. PU incidence was 8.3%, with 95% confidence interval (CI) of 4.5 to 13.7%. The majority (76.9%) of PUs developed in the first three days of admission. On admission, 28 patients were found to be hypotensive, and 129 non-hypotensive. In the hypotensive group, PU incidence was 21.4% (6/28), and 5.4% (7/129) in the non-hypotensive group, respectively. The crude OR was 4.753 (95%CI: 1.183 to 18.086). After adjustment by patients' age, admission to emergency intensive care unit and if requiring assistance to move, the adjusted OR of hypotension on admission for PU risk was 1.755 (95%CI: 1.356 to 3.224).

CONCLUSION

Our study showed that admission hypotension was an independent risk factor of PU among elderly patients in emergency department. However, this conclusion should be confirmed by further studies with large sample size.

Pressure injuries in elderly with acute myocardial infarction

Objectives

To assess pressure injury (PI) incidence among patients hospitalized for acute myocardial infarction (AMI) in an intensive coronary care unit (ICCU) and to detect the impact of specific risk factors on the development of PI in this clinical setting.

Patients and methods

Prospective cohort study in ICCU setting. Patients admitted for AMI: patients mean age 67.5±11.5 years (n=165). Norton Scale, Mini Nutritional Assessment (MNA), demographic, clinical and biochemical data collected at the time of ICCU admission have been tested in a logistic model to assess the odds ratios (ORs) of PI risk development. The jackknifed area under the receiver operating characteristic curve (AUC) and the decision curve analysis have been employed to assess the additive predictive value of a factor.

Results

Twenty-seven (16.3%) patients developed PIs. An increased PI risk was associated with advanced age (OR =2.5 every 10-year increase; 95% CI =1.1–5.7), while probability of PI development was reduced in patients with higher left ventricular ejection fraction (LVEF) (OR =0.4 every 5% increase; 95% CI =0.24–0.66), MNA score (OR =0.65 every unit change; 95% CI =0.44–0.95) and Norton Scale score (OR =0.7 every unit change; 95% CI =0.57–0.88). The AUC and the decision curve analysis showed that LVEF inclusion improved the discrimination power and the clinical net benefit of the final model.

Conclusion

Age, LVEF, Norton Scale and MNA scores have a strong and independent clinical value as predictors of in-hospital PI development in patients with AMI. This finding has the potential to improve the clinical management of patients admitted in ICCU.

Attitudes of Nursing Students About Pressure Injury Prevention

PURPOSE

The objective of this study was to examine the attitudes of baccalaureate nursing students toward their role in pressure injury prevention (PIP) and describe how clinical experiences influence their attitudes. Understanding students' attitudes and experiences related to PIP may facilitate development of evidence-based interventions for PIP by nurses.

DESIGN

Qualitative exploratory descriptive design.

SETTING AND SUBJECTS

Participants were 16 senior nursing students enrolled in a prelicensure baccalaureate nursing program in an accredited school of nursing. Half of the participants had completed their first 2 years of the nursing major in the baccalaureate program. The remaining participants completed their first 2 years in a community college associate degree nursing program.

METHOD

Semistructured, in-depth, open-ended interviews were conducted. Interviews were digitally recorded and transcribed verbatim; data were analyzed for key themes using content analysis.

RESULTS

Four categories of attitudes about PIP were identified: (1) ambivalence, (2) emerging awareness, (3) committed, and (4) passionate. Diverse clinical experiences in pediatrics, the operating room, trauma units, and long-term care facilities enhanced nursing students' learning related to PIP. Experiences observing WOC nurses and other staff role models engaged in PIP were associated with student commitment and passion for PIP.

CONCLUSIONS

Findings from this study can be used to guide interventions to enhance attitudes of commitment to PIP. WOC nurses, clinical preceptors, and clinical staff can involve nursing students in intentional PIP learning activities to improve clinical practice and patient outcomes. Intentionally incorporating key learning activities about PIP in the nursing curriculum is recommended.

Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study

STUDY DESIGN

Secondary analysis of data from a prospective cohort study.

OBJECTIVES

The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury.

SETTING

The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States.

METHODS

Adults with acute traumatic spinal cord injury (n=104) were recruited within 24-72 h of admission to the hospital. Pressure ulcer incidence was recorded.

RESULTS

Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1-20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3-16.63), P=0.01.

CONCLUSION

Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

Bacterial Contribution in Chronicity of Wounds

A wound is damage of a tissue usually caused by laceration of a membrane, generally the skin. Wound healing is accomplished in three stages in healthy individuals, including inflammatory, proliferative, and remodeling stages. Healing of wounds normally starts from the inflammatory phase and ends up in the remodeling phase, but chronic wounds remain in an inflammatory stage and do not show progression due to some specific reasons. Chronic wounds are classified in different categories, such as diabetic foot ulcer (DFU), venous leg ulcers (VLU) and pressure ulcer (PU), surgical site infection (SSI), abscess, or trauma ulcers. Globally, the incidence rate of DFU is 1-4 % and prevalence rate is 5.3-10.5 %. However, colonization of pathogenic bacteria at the wound site is associated with wound chronicity. Most chronic wounds contain more than one bacterial species and produce a synergetic effect that results in previously non-virulent bacterial species becoming virulent and causing damage to the host. While investigating bacterial diversity in chronic wounds, Staphylococcus, Pseudomonas, Peptoniphilus, Enterobacter, Stenotrophomonas, Finegoldia, and Serratia were found most frequently in chronic wounds. Recently, it has been observed that bacteria in chronic wounds develop biofilms that contribute to a delay in healing. In a mature biofilm, bacteria grow slowly due to deficiency of nutrients that results in the resistance of bacteria to antibiotics. The present review reflects the reasons why acute wounds become chronic. Interesting findings include the bacterial load, which forms biofilms and shows high-level resistance toward antibiotics, which is a threat to human health in general and particularly to some patients who have acute wounds.

Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis

Background:

Historically, complication rates after pressure ulcer reconstruction utilizing flap coverage have been high. Patients undergoing operations for pressure ulcer coverage typically have multiple risk factors for postoperative complications. The purpose of this study was to examine a large patient series in the pressure ulcer population to uncover objective evidence of the linkage between risk factors and outcomes after flap coverage.

Methods:

This study was a retrospective chart review of patients who underwent flap reconstruction for a pressure ulcer between 1997 and 2015. The characteristics of patients were analyzed to determine those who had complications such as pressure ulcer recurrence, wound dehiscence, and wound infection.

Results:

All patients (N = 276) underwent flap coverage of their pressure ulcers. The overall complication rate was 58.7% (162 patients). Wound dehiscence was the most common complication (31.2%), and the pressure ulcer recurrence rate was 28.6%. Multivariate regression for pressure ulcer recurrence revealed that body mass index <18.5 [relative risk (RR) 3.13], active smoking (RR 2.33), and ischial pressure ulcers (RR 3.46) were independent risk factors for pressure ulcer recurrence. Ischial pressure ulcers (RR 2.27) and preoperative osteomyelitis (RR 2.78) were independent risk factors for wound dehiscence. Diabetes was an independent risk factor for wound infection (RR 4.34).

Conclusions:

Our retrospective analysis revealed numerous factors that are associated with high rates of major postoperative complications. Risk factors must be taken into account when offering flap coverage, and risk-reducing strategies must be implemented in patients before pressure ulcer reconstruction.

Predictive Factors for Pressure Ulcers in an Older Adult Population Hospitalized for Hip Fractures: A Prognostic Cohort Study

Background

Older adult patients with fragility hip fractures constitute a population at high risk for complications, in particular pressure ulcers. The aim was to evaluate the incidence of pressure ulcers and potential predictive factors.

Methods and Findings

A prospective multicentric prognostic cohort study in orthopedic wards in three Italian public hospitals. Participants were all consecutive patients 65 years of age or older diagnosed with a fragility hip fracture. Outcomes were incidence of pressure ulcers. The exposure variables were grouped into three macro areas in order to facilitate reading: “intrinsic” variables, “extrinsic” variables and variables linked to the organization of patient care. One thousand eighty-three older adult patients with fragility hip fractures were enrolled from October 1^st, 2013 to January 31^st, 2015, and pressure ulcers developed in 22.7%. At multivariate analysis, the following were found to be risk factors: age> 80 years (odds ratio (OR) 1.03; p = 0.015), the length of time a urinary catheter was used (OR 1.013; p<0.001), the length of time pain was present (OR 1.008; p = 0.008), the absence of side rails on the bed (OR 1.668; p = 0.026) and the use of a foam position valve (OR 1.025; p<0.001). Instead, the protective factors were the presence of a caregiver for at least half a day daily (OR 0.994; p = 0.012) and the number of positionings during the postoperative period (OR 0.897; p = 0.008).

Conclusions

The study allowed the identification of the patients most at risk for developing pressure ulcers, and the construction of a pragmatic predictive model using significant risk or protective factors in order to reduce the number of pressure ulcers.

[Risk factors of pressure ulcers in hospitalized patients of a Portuguese hospital]

OBJECTIVE

To identify and characterize the risk factors of pressure ulcers (PU) in patients admitted in a Portuguese Hospital.

MATERIALS AND METHODS

Descriptive and cross-sectional study with a sample consisting of 34 individuals, 70.6 % male and 29.4 % female with a mean age of 78.93 ± 6.05 years. The data collection instrument consisted of an analysis grid that contains socio-demographic, clinical and therapeutic data. Descriptive statistics, and inferential analysis were estimated, the chi-square test of Pearson was used for p≤0.05.

RESULTS

Data analysis found that individuals already presented with PU upon admission to the hospital, and that most of them stay between 6 days and 1 month; the longer the hospitalization period, the longer the hospitalization time, the greater the number of PU developed by individuals. Most PU patients have a strong prevalence of severe PU in the sacrum and calcaneus region, and hypertension, respiratory disease and Diabetes mellitus are the most frequent pathologies.

CONCLUSION

The current gloomy picture of PUs can only be changed if there is greater investment in prevention and accurate treatment. In this sense, guidelines should be systematized for families during hospitalization and outpatient monitoring.

Pathway from Delirium to Death: Potential In-Hospital Mediators of Excess Mortality

OBJECTIVES

(1) To determine the relationship of incident delirium during hospitalization with 90-day mortality; (2) to identify potential in-hospital mediators through which delirium increases 90-day mortality.

DESIGN

Analysis of data from Project Recovery, a controlled clinical trial of a delirium prevention intervention from 1995 to 1998 with follow-up through 2000.

SETTING

Large academic hospital.

PARTICIPANTS

Patients ≥70 years old without delirium at hospital admission who were at intermediate-to-high risk of developing delirium and received usual care only.

MEASUREMENTS

(1) Incident delirium; (2) potential mediators of delirium on death including use of restraining devices (physical restraints, urinary catheters), development of hospital acquired conditions (HACs) (falls, pressure ulcers), and exposure to other noxious insults (sleep deprivation, acute malnutrition, dehydration, aspiration pneumonia); (3) death within 90 days of admission.

RESULTS

Among 469 patients, 70 (15%) developed incident delirium. These patients were more likely to experience restraining devices (37% vs 16%, P < .001), HACs (37% vs 12%, P < .001), other noxious insults (63% vs 49%, P = .03), and 90-day mortality (24% vs 6%, P < .001). The inverse probability weighted hazard of death due to delirium was 4.2 (95% CI = 2.8-6.3) in bivariable analyses, increased in a graded manner with additional exposures to restraining devices, HACs, and other noxious insults, and declined by 10.9% after addition of these potential mediator categories, providing evidence of mediation.

CONCLUSION

Restraining devices, HACs, and additional noxious insults were more frequent among patients with delirium, increased mortality in a graded manner, and were responsible for a significant percentage of the association of delirium with death. Additional efforts to prevent potential downstream mediators through which delirium increases mortality may help to improve outcomes among hospitalized older adults.

The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial

BACKGROUND

Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality.

OBJECTIVE

To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients.

DESIGN

Pragmatic cluster randomised trial.

SETTING

Eight tertiary referral hospitals with >200 beds each in three Australian states.

PARTICIPANTS

1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English.

METHODS

Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection.

RESULTS

Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported.

CONCLUSIONS

Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.

Association of statins with diabetes mellitus and diabetic complications: role of confounders during follow-up

Studies have associated statin use with increased risk of diabetes and diabetic complications. These studies often ensure comparability of statin users and non-users at baseline; however, most studies neglect to consider confounders that occur during follow-up. Failure to consider these confounders, such as new medications or procedures, may result in identification of a spurious association between statins and outcomes. The objective of this study was to examine the association of statins with diabetes mellitus and diabetic complications; and to examine potential confounders during the follow-up period that might affect this relationship. We conducted a retrospective cohort study using Tricare data (from October 1, 2003 to March 31, 2012). We propensity score-matched statin users and non-users on 115 baseline characteristics before starting statins; these characteristics would be potentially associated with the use of statins or the outcomes of interest. Outcomes included the risk of diabetes mellitus and diabetic complications. Out of 60,455 patients (10,910 statin users and 49,545 non-users), we propensity score-matched 6728 statin users to 6728 non-users. Statin users had higher ORs for diabetes (OR 1.34, 95% CI 1.24 to 1.44) and diabetes with complications (OR 1.28, 95% CI 1.16 to 1.42). Adjustment for potential confounders that occurred during the follow-up period did not explain or diminish the association between statins and adverse outcomes. Statin users in comparison to similar non-users were more commonly diagnosed with diabetes and diabetic complications, even after adjustment for potential confounders that occurred during the follow-up period.

Predictors of pressure ulcer development in patients with vascular disease

BACKGROUND

Although pressure ulcer (PU) risk factors are well known in the general population, little research is available in hospitalized surgical patients admitted with vascular diseases.

METHODS

Using a retrospective medical records review, characteristics of hospitalized surgical patients with vascular diseases were assessed. Variables were based on literature review of PUs and availability of medical records and administrative data. Trained registered nurses collected data. Analyses included descriptive and comparative statistics, and multivariable modeling was used to determine predictors of PU.

RESULTS

In 849 adult admissions, 18.9% had a PU; 11.8% were hospital-acquired PU (HAPU). Patients were more likely to be elderly, male (n = 575; 67.7%), and Caucasian (n = 704; 83.3%). Common diagnoses were aneurysms/embolisms (43.2%) and atherosclerosis (31.2%). Patients with HAPU were more likely to be discharged to a skilled nursing or other facility compared with home (P < .001). In univariate analyses, 12 patient characteristics were associated with HAPU presence: Female gender, non-married status, current smoker, non-Caucasian race, non-intensive care unit (ICU) stay, primary diagnosis of atherosclerosis, higher analgesic use, higher right ankle brachial index (ABI), lower Braden score, higher blood urea nitrogen (BUN) higher serum creatinine and higher total protein levels. In multivariate analyses, nine factors predicted HAPU: Lower right ABI and Braden score, an ICU stay, low and high hematocrit values, female gender, non-White race, atherosclerosis history, and higher BUN and body mass index (BMI). The concordance index for the nine-item model was 0.854.

CONCLUSION

The rate of HAPU in hospitalized surgical patients with vascular diseases was greater than expected. Assessment of important HAPU factors and implementation of interventions are needed to decrease risk and improve clinical outcomes.

Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults

BACKGROUND

Statin use is associated with increased incidence of diabetes and possibly with increased body weight and reduced exercise capacity. Data on the long-term effects of these associations in healthy adults, however, are very limited. In addition, the relationship between these effects and diabetic complications has not been adequately studied.

OBJECTIVE

To examine the association between statin use and new-onset diabetes, diabetic complications, and overweight/obesity in a cohort of healthy adults.

RESEARCH DESIGN

This was a retrospective cohort study.

PARTICIPANTS

Subjects were Tricare beneficiaries who were evaluated between October 1, 2003 and March 1, 2012. Patients were divided into statin users and nonusers.

INTERVENTION

We excluded patients who, at baseline, had a preexisting disease indicative of cardiovascular diseases, any positive element of the Charlson comorbidity index (including diabetes mellitus), or life-limiting chronic diseases. Using 42 baseline characteristics, we generated a propensity score to match statin users and nonusers.

MAIN MEASURES

Outcomes assessed included new-onset diabetes, diabetic complications, and overweight/obesity.

KEY RESULTS

A total of 25,970 patients (3982 statin users and 21,988 nonusers) were identified as healthy adults at baseline. Of these, 3351 statins users and 3351 nonusers were propensity score-matched. Statin users had higher odds of new-onset diabetes (odds ratio [OR] 1.87; 95 % confidence interval [95 % CI] 1.67-2.01), diabetes with complications (OR 2.50; 95 % CI 1.88-3.32), and overweight/obesity (OR 1.14; 95 % CI 1.04-1.25). Secondary and sensitivity analyses demonstrated similar findings.

CONCLUSIONS

Diabetes, diabetic complications, and overweight/obesity were more commonly diagnosed among statin-users than similar nonusers in a healthy cohort of adults. This study demonstrates that short-term clinical trials might not fully describe the risk/benefit of long-term statin use for primary prevention.

The psychometric performance of generic preference-based measures for patients with pressure ulcers

BACKGROUND

Pressure ulcers are wounds that result from reduced mobility, and can have a significant impact on morbidity, mortality and quality of life. As pressure ulcers are a consequence of a wide range of conditions and interventions, it is unclear whether the best means of capturing the quality of life impacts is via generic or condition specific Patient Reported Outcome Measures (PROMs). The aim of this study was to investigate the psychometric performance of the generic EQ-5D and SF-6D amongst patients identified as having or being at risk of developing pressure ulceration.

METHODS

A survey of patients who were using pressure relieving mattresses and other equipment was undertaken within inpatient and community settings using a handheld tablet and postal survey. Data on EQ-5D-3L, SF-12 (used to calculate SF-6D), an EQ-5D dignity bolt-on question, demographic and wound specific questions were collected. Convergent validity was assessed using Spearman's correlations, and agreement using Bland-Altman plots. Known group validity was assessed by examining whether the instruments discriminated between different pressure ulcer severity groups. Multivariate linear regression was used to examine the impact of a range of pressure ulcer related variables.

RESULTS

The total number of participants was 307, including 273 from the acute setting (52% response rate) and 41 from the community (32%). SF-6D and EQ-5D were moderately correlated (0.61), suggesting that both instruments were capturing similar quality of life impacts. Both measures were able to significantly discriminate between groups based on the ulcer grade. Presence of a pressure ulcer and number of comorbidities were significant explanatory variables of EQ-5D and SF-6D score.

CONCLUSIONS

The results suggest that generic PROMs can effectively capture the impact of pressure ulcers on quality of life, although there are significant challenges in collecting data from this group of patients related to poor clinical condition and mental capacity. The most effective method for obtaining survey data was through the hand held devices and interviewers.

Knowledge and practice of nurses towards prevention of pressure ulcer and associated factors in Gondar University Hospital, Northwest Ethiopia

Background

Pressure ulcers are the common conditions among patients hospitalized in acute and chronic care facilities and impose significant burden on patients, their relatives and caregivers. Pressure ulcers have been described as one of the most costly and physically debilitating complications since the 20^th century. The pain and discomfort due to pressure ulcer prolongs illness, rehabilitation, time of discharge and even contribute to disability and death. This study was aimed to assess knowledge, practice and factors associated with pressure ulcer prevention among nurses in Gondar University Hospital, North-west Ethiopia.

Method

An institution-based cross-sectional survey was conducted from March 15 - April 10, 2014 among 248 nurses in Gondar University hospital. A pretested and structured self-administered questionnaire was used for data collection. Data were entered using EPI info version 3.5.3 statistical software and analyzed using SPSS version 20 statistical package. Descriptive statistics was used to describe the study population in relation to relevant variables. Bivariate and multivariate logistic regression was also carried out to see the effect of each independent variable on the dependent variable.

Result

Nearly half (54.4 %) of the nurses had good knowledge; similarly 48.4 % of them had good practice on prevention of pressure ulcer. Educational status [Adjusted Odds Ratio (AOR) = 2.4, 95 % CI (1.39-4.15)], work experience [AOR = 4.8, 95 % CI (1.31-10.62)] and having formal training [AOR = 4.1, 95 % CI (1.29-9.92)] were significantly associated with knowledge on prevention of pressure ulcer. While, satisfaction with nursing leadership [AOR = 1.9, 95 % CI (1.04-3.82)], staff shortage [AOR = 0.07, 95 % CI (0.03-0.13)] and inadequate facilities and equipment [AOR = 0.4, 95 % CI (0.19-0.83)] were found to be significantly associated with the practice on prevention of pressure ulcer.

Conclusion

Knowledge and practice of the nurses regarding prevention of pressure ulcer was found to be inadequate. Having higher educational status, attending formal training and being experienced were positively associated with knowledge; while shortage of facilities and equipments, dissatisfaction with nursing leadership and inadequate staff number showed negative association with practice of nurse’s pressure ulcer prevention. In-service training and upgrading courses are some of the important steps to improve nurses’ knowledge and practice on prevention of ulcer pressure.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-015-0076-8) contains supplementary material, which is available to authorized users.