Reducing pressure ulcer incidence in a long-term setting

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages, and impact on PU prevention-A quasi-experimental intervention study

This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for residents. A quasi-experimental intervention study was conducted. The data were collected from 232 residents (n = 115 in intervention and 117 in comparison group) in two public long-term older people care (LOPC) facilities in Finland using the Pressure Ulcer Patient instrument (PUP-Instrument). The facilities were chosen with convenience sampling, after which they were randomly allocated as either intervention or comparison facility. Based on international guidelines for PU prevention, the renewed, consistent PU prevention practice with six areas was developed and implemented using the operational model for evidence-based practices (OMEBP). After the intervention, a significant difference between the intervention and the comparison facility was seen in the prevalence of PUs and in the residents' highest stage of PUs in the sacrum, buttock and hip areas, and heels. Between the facilities, a significant difference was seen in the use of PU and nutrition risk assessment instruments and nutritional supplements, time used for repositioning in the daytime and at night-time, lifting belt use, and avoiding shearing or stretching residents' skin. The successful intervention improved skin integrity in LOPC facilities.

Preventive interventions for pressure ulcers in long-term older people care facilities: A systematic review

AIMS AND OBJECTIVES

To explore the effectiveness of interventions aimed at pressure ulcer (PU) prevention in long-term older people care facilities (LOPC).

BACKGROUND

Pressure ulcers cause suffering for patients and constitute a major financial burden. Although most PUs could be prevented, their number has remained high. To avoid unnecessary suffering and costs, PU prevention must be effective.

DESIGN

A systematic review.

METHODS

A systematic search was conducted in six electronic databases PubMed (MEDLINE), CINAHL, Web of Science Core Collection, Scopus, Cochrane Wounds Group Specialized Register and Cochrane Central Register of Controlled Trials. The inclusion criteria were: (a) study published in 2005-2017, (b) intervention with pre- and post-tests, focusing on PU prevention, (c) implemented in LOPC facilities, (d) persons >65 years as study population, and (e) outcomes reported as PU incidence or prevalence or healing time. The PRISMA guidelines were followed. The methodological quality of the studies was evaluated using the Joanna Briggs Institute's MAStARI critical appraisal checklist. The data were analysed with narrative synthesis.

RESULTS

The review included eighteen studies. The study designs were RCTs (n = 10), comparable cohort or case-control studies (n = 3), and descriptive or case series (n = 5). PU incidence in LOPC facilities decreased by using computerised decision-making support systems, PU prevention programmes, repositioning or advanced cushions. PU prevalence decreased with PU prevention programmes, by using advanced mattresses and overlays, or by adding protein and energy supplements to diet.

CONCLUSIONS

There are many ways to prevent PUs in LOPC facilities; no single effective way can be identified. One-third of the preventive interventions in LOPC facilities were effective. However, systematic evidence from randomised trials on preventive interventions of PUs in LOPC settings is still lacking.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used in practice for selecting and in research for developing effective preventive interventions of PUs in LOPC facilities.

Understanding the Hawthorne effect in wound research-A scoping review

The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.

The Integrity Full Replacement Alternating Mattress

The Integrity Full Replacement Alternating Mattress, manufactured and distributed by Sumed, is an innovative alternative for those users who find conventional alternating pressure mattresses uncomfortable. The mattress is designed with smaller cells than conventional alternating mattresses and this has a number of benefits for the user, in that posture within the bed is not compromised as the cells alternatively inflate and deflate, maintaining mobility and function. Furthermore, users report that the small cell size results in their experiencing far more comfort on this mattress comparered with other alternating mattresses previously tried, as they feel far less movement with the alternation. Importantly, the construction of the mattress affords significant safety to the user in the event of power failure, and this is particularly pertinent in the community setting where the user is monitored less frequently. This article discusses pressure injury prevention in the community and describes how the Integrity mattress provides a solution.

Friction and shear highly associated with pressure ulcers of residents in long-term care - Classification Tree Analysis (CHAID) of Braden items

AIMS

Among various risk assessment scales for the development of pressure ulcers in long-term care residents that have been published in the last three decades, the Braden scale is among the most tested and applied tools. The sum score of the scale implies that all items are equally important. The aim of this study is to show whether specific items are of greater significance than others and therefore have a higher clinical relevance.

DESIGN

Data analysis of six pressure ulcer prevalence studies (2004-2009).

METHODS

A total of 17,666 residents (response rate 79.6%) in 234 long-term care facilities participated in 6 annual point prevalence studies that were conducted from 2004 to 2009 throughout Germany. For the classification of the sample regarding pressure ulcers as a dependent variable and the Braden items as predictor variables, Chi-square Automatic Interaction Detector (CHAID) for modelling classification trees has been used.

RESULTS

Pressure ulcer prevalence was 5.4% including pressure ulcer grade 1 and 3.4% for pressure ulcer grades 2-4. CHAID analysis for the classification tree provided the item 'friction and shear' as the most important predictor for pressure ulcer prevalence. On the second level, the strongest predictors were 'nutrition' and 'activity' and on the third level they were 'moisture' and 'mobility'. Residents with problems regarding 'friction and shear' and poor nutritional status present with an 18.0 (14.8) pressure ulcer prevalence which is 3-4 times higher than average.

CONCLUSION

CHAID analyses have shown that all items of the Braden scale are not equally important. For residents in long-term care facilities in Germany, the existence of 'friction and shear' as a potential and especially as a manifest problem has had the strongest association with pressure ulcer prevalence.

Wound healing in older adults

Chronic wounds affect a substantial number of individuals throughout the world, and impose a significant psychological, physical and economic burden. As the population ages, the incidence of chronic wounds is also expected to rise. Clinicians struggle to find the optimal approaches to prevention and treatment of these nonhealing or slow-healing wounds. This review discusses current best practices and evidence-based recommendations for preventing and managing chronic wounds in general, as well as pressure ulcers, diabetic foot ulcers and venous leg ulcers specifically. This review highlights the significant gaps and inconsistencies in the current evidence base for chronic wound care, which have hindered making substantial progress in improving wound healing rates. It concludes with recommendations for improving the research and clinical knowledge base related to optimal wound-care practices.

Surgical critical care: from old boundaries to new frontiers

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.

Challenges and obstacles in measuring outcomes

Numerous factors contribute to the need for consultant pharmacists to understand and measure outcomes. Consumer groups, legislatures, regulatory and certification agencies, among others, are interested in this information. The science of quality improvement is still young. Distinguishing among three terms--quality indicators, quality measures, and benchmarks--is easy enough once they become familiar. The roots of most long-term care quality models rest on the Donabedian model. Care is necessary when selecting outcomes measures because several pitfalls exist. When carefully selected, outcomes measures can improve care immensely and decrease the risk of adverse events.