The prevalence of pressure ulcers in hospitalised patients in a university hospital in India

Burden of Chronic Nonhealing Wounds: An Overview of the Worldwide Humanistic and Economic Burden to the Healthcare System

Chronic wounds have long been a significant public health concern, but the true impact of these wounds is unknown since research designs and measuring techniques vary, leading to inconsistent estimates. The definition of a wound is a loss of epithelial continuity caused by damage to the tissue. The following conditions can cause chronic wounds: panniculitis, pyoderma gangrenosum, traumatic, neurological, metabolic, hematologic, neoplastic, or infection-related. The growing global incidence of diabetes and the aging population necessitate greater attention to chronic wounds. Regrettably, it is sad that significant healthcare institutions have overlooked wound research. The study of health-related illnesses and occurrences in particular populations, including their distribution, frequency, and determinants, and the application of this research to control health problems.

Aetiology, risk factors and treatment of typical and atypical pressure ulcers in patients with traumatic brain injury: A narrative review

Pressure ulcers are one of the leading complications in bedridden patients that result in multiple burdens on healthcare systems and patients (11 billion dollars/year). The prevalence of pressure ulcers in traumatic brain injury patients is 1.5-fold compared with the other bedridden patients. Moreover, critical traumatic brain injury patients who are admitted to the intensive care unit experience severe pressure ulcers and further complications. The motor/sensory disabilities and low supplementation and oxygenation to the pressured side were the main mechanisms of the typical pressure ulcers. Intellectual evaluation is the first essential step to prevent the development of pressure ulcers in high-risk patients. Till now, different scales, including Injury Scale Score and Braden Scale Score, have been provided to assess the pressure ulcer. Since low stages of pressure ulcers heal rapidly, traumatic brain injury patients require a periodical assessment to prevent further developments timely. Alongside different procedures provided to prevent and treat any pressure ulcer, traumatic brain injury patients required additional specific protections. For the first line, fast and efficient rehabilitation repairs motor/sensory disabilities and decreases the chance of pressure ulcer. Our review indicated that pressure ulcer in traumatic brain injury had several complex mechanisms that demand special care. Therefore, further studies are required to address these mechanisms and prevent their progression to typical and atypical pressure ulcers.

Unhealed Pressure Ulcers Among Nursing Home Residents with Diabetes

INTRODUCTION

Nearly a third of US nursing home residents have diabetes mellitus. These residents have an increased risk of pressure ulcer (PU) development and progression; however, little is known about the characteristics of their PUs or the role of other risk factors. This study estimates the prevalence of PUs, describes characteristics of PUs, and quantifies associations between risk factors and PUs in nursing home residents with diabetes.

METHODS

We conducted a cross-sectional study of nursing home residents aged ≥50 years with diabetes mellitus using national 2016 Minimum Data Set 3.0 data. Pressure ulcers were defined as the presence of any stage PU and by subgroups of stage and tissue type. Prevalence estimates of PUs were calculated overall and by covariate subgroups. Unadjusted and adjusted odds ratios were calculated using logistic regression.

RESULTS

The prevalence of any unhealed PU was 8.1%. Of those with a PU, 19.4% had at least two ulcers and the most common subtypes were identified as unstageable and stage 2 ulcers. These were most often treated by pressure reducing devices. In our fully adjusted model, risk factors that were strongly associated with PUs were related to mobility, nutrition, incontinence, and infections.

CONCLUSION

We observed that the prevalence of PUs remains high in nursing home residents with diabetes and that higher stage ulcers were common in this population. Our adjusted model highlights the importance of suspected risk factors in the development of PUs. Further research is needed to understand the unique needs of nursing home residents with diabetes.

Effectiveness of a continuous patient position monitoring system in improving hospital turn protocol compliance in an ICU: A multiphase multisite study in India

Purpose

Hospital-acquired pressure ulcers are a significant cause of morbidity and consume considerable financial resources. Turn protocols (repositioning patients at regular intervals) are utilized to reduce incidence of pressure ulcers. Adherence to turn protocols is particularly challenging for nursing teams, given the high number of interventions in intensive care unit, and lack of widely available tools to monitor patient position and generate alerts. We decided to develop and evaluate usefulness of a continuous patient position monitoring system to assist nurses in improving turn protocol compliance.

Methods

We conducted a prospective, non-randomized, multiphase, multicentre trial. In Phase I (control group), the function of the device was not revealed to nurses so as to observe their baseline adherence to turn protocol, while Phase II (intervention group) used continuous patient position monitoring system to generate alerts, when non-compliant with the turn protocol. All consecutive patients admitted to one of the two intensive care units during the study period were screened for enrolment. Patients at risk of acquiring pressure ulcers (Braden score < 18) were considered for the study (Phase I (N = 22), Phase II (N = 25)).

Results

We analysed over 1450 h of patient position data collected from 40 patients (Phase I (N = 20), Phase II (N = 20)). Turn protocol compliance was significantly higher in Phase II (80.15 ± 8.97%) compared to the Phase I (24.36 ± 12.67%); p < 0.001.

Conclusion

Using a continuous patient position monitoring system to provide alerts significantly improved compliance with hospital turn protocol. Nurses found the system to be useful in providing automated turn reminders and prioritising tasks.

Proximal femoral resection and Tensor Fascia Lata flap for recalcitrant trochanteric pressure ulcers

Introduction

Trochanteric pressure ulcers (PrUs) are difficult to treat and are often complicated by infection spreading to the hip joint. We review three cases from India where proximal femoral resection and pedicled Tensor Fascia Lata (TFL) flapping was used in the management of infected deep trochanteric ulcers communicating to the hip joint.

Case presentation

Three patients had a total of four trochanteric PrUs communicating to the hip joint. Proximal femoral resection along with radical debridement of the pressure ulcer (PrU) was the first step in our surgical protocol. Serial debridements were performed to make the resulting cavity healthier and ready for the subsequent flap surgery. TFL flapping was done to cover the raw area of the PrU and the donor site was closed either primarily or with a split skin graft. All patients were males with AIS A spinal cord injury (SCI) and stage 4 PrUs in the trochanteric region. One patient had bilateral trochanteric ulcers. There was complete healing of all PrUs with improvement in wheelchair mobility, and general health.

Discussion

PrUs are a common complication of patients with SCI and are often considered one of the most neglected issues of health care delivery in India. Proximal femoral resection with pedicled TFL muscle flap is a versatile and reliable procedure for the coverage of recalcitrant trochanteric PrU with hip joint involvement. Minimal donor site morbidity occurs.

Pressure Ulcers Prevalence in the Acute Care Setting: A Systematic Review, 2000-2015

Little is known about the prevalence of pressure ulcer (PrU) in acute care settings. The aim of this study is to determine the prevalence rate of PrU in acute care settings and to assess the methodological quality of the reviewed publications. The Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, MEDLINE, and Cochrane Database of Systematic Reviews were searched using the keywords pressure ulcer or decubitus ulcer or bed sore or pressure sore or pressure injury, with prevalence and acute care, for studies published between January 2000 and December 2015. Nineteen publications met our criteria. These reported a prevalence range of between 7.8% and 54% for those using European Pressure Ulcer Advisory Panel methodology, 6% and 22% for those using National Pressure Ulcer Advisory Panel methodology, and 4.94% for the study that employed the Torrance system. The likely worldwide PrU prevalence rate range in acute care settings is between 6% and 18.5%. Prevalence rate varies between studies depending on the methodology of data collection. Moreover, the methodological quality of the included studies in the review was variable; therefore, it was difficult to compare the prevalence rate between the studies, settings, and countries.

Pressure Ulcer Surveillance in Neurotrauma Patients at a Level One Trauma Centre in India

OBJECTIVES

Pressure ulcers are a multifactorial, prevalent, and preventable morbidity. They cause a burden both financially and emotionally, to the individual, their family and doctor, and to society as a whole. Pressure ulcers are extremely difficult to treat; therefore, prevention is key.

METHODS

We started a Wound Care Surveillance Program in 2012 involving nurses, physiotherapists, and doctors. We intended to prevent the occurrence of pressure ulcers, ensure early detection, and facilitate the healing process. The Braden scale was used to stratify patients' risk. The number of patients observed in our study was 2,974 over a one-year period.

RESULTS

The pressure sore prevalence was 3.1%. Younger and middle-aged patients were most commonly affected; 27% of these patients did not survive. Mortality was not attributed to the pressure ulcer directly. The most common mode of injury was road traffic accidents. Most of our patients had just a single pressure area affected, most commonly the sacrum. Most patients were managed with debridement and dressings while 12% received surgical treatment. Of those with stage one ulcers, 29% healed completely at two months. In stage two and three patients, 17% and 6% healed in two months, respectively, and this number was zero in stage four patients.

CONCLUSION

The Wound Care Surveillance Program has been a very effective strategy for the prevention and management of pressure ulcers. Stage two ulcers were the most common in our setup. Braden scoring, traditionally used to screen these ulcers, can be used as a predictive and prognostic tool to predict healing of pressure ulcers. Poor healing is expected in higher staged ulcers and patients with spinal injury and major solid organ injury and those who need a tracheostomy. Home-based care is not up to mark in our society and accounts for most of the cases in the follow-up.

Burden and outcomes of pressure ulcers in cancer patients receiving the kerala model of home based palliative care in India: results from a prospective observational study

AIM

To report the prevalence and outcomes of pressure ulcers (PU) seen in a cohort of cancer patients requiring home-based palliative care.

MATERIALS AND METHODS

All patients referred for home care were eligible for this prospective observational study, provided they were living within a distance of 35 km from the institute and gave informed consent. During each visit, caregivers were trained and educated for providing nursing care for the patient. Dressing material for PU care was provided to all patients free of cost and care methods were demonstrated. Factors influencing the occurrence and healing of PUs were analyzed using logistic regression. Duration for healing of PU was calculated using the Kaplan Meier method. P < 0.05 are taken as significant.

RESULTS

Twenty-one of 108 (19.4%) enrolled patients had PU at the start of homecare services. None of the patients developed new PU during the course of home care. Complete healing of PU was seen in 9 (42.9%) patients. The median duration for healing of PU was found to be 56 days. Median expenditure incurred in patients with PU was Rs. 2323.40 with a median daily expenditure of Rs. 77.56.

CONCLUSIONS

The present model of homecare service delivery was found to be effective in the prevention and management of PUs. The high prevalence of PU in this cohort indicates a need for greater awareness for this complication.

CLINICAL TRIAL REGISTRY NUMBER

CTRI/2014/03/004477.

Pressure ulcer in patients with severe traumatic brain injury: significant factors and association with neurological outcome

AIMS AND OBJECTIVES

To assess the factors associated with development of pressure ulcer in patients with severe traumatic brain injury (TBI) and study its prognostic significance with respect to neurological outcome at three months.

BACKGROUND

Patients with severe TBI are prone to develop pressure ulcer due to various factors, which have never been studied in detail.

DESIGN

Prospective longitudinal study.

METHODS

Eighty-nine patients of TBI in age group 20-60 years admitted with Glasgow Coma Scale (GCS) 4-8 without serious systemic disorder were enrolled for the study. Patient characteristics, haemoglobin, serum albumin levels at admission and their weekly changes till 21 days were noted along with daily assessment for presence of pressure ulcer. Mortality was assessed at 21 days and neurological outcome at three months through telephonic interview.

RESULTS

Of 89 patients studied, pressure ulcer was observed in 6 (7%) and 14 (16%) at the end of two and three weeks, respectively. Pressure ulcer in univariate analysis was significantly associated with poorer GCS (p = 0·05), delayed enteral feeding (p = 0·005) and fall in haemoglobin at two weeks (p = 0·005). Only the latter two were found significant in multivariate analysis. Age, gender, surgical intervention, tracheostomy, prolonged fever and change in albumin had no significant association with pressure ulcer development. Presence of pressure ulcer was significantly associated with mortality at 21 days (p = 0·006) and unfavourable neurological outcome at three months (p = 0·01).

CONCLUSIONS

The significant factors influencing pressure ulcer development in patients with TBI were delayed enteral feeding and fall in haemoglobin. Pressure ulcer had significant association with mortality at 21 days and recovery status at three months.

RELEVANCE TO CLINICAL PRACTICE

Early nutritional supplementation and monitoring of haemoglobin should be an important part of nursing care interventions for patients at increased risk of developing pressure ulcer.

Systemic factors and mortality in elderly patients with pressure ulcers

The aim of this article was to identify specific systemic factors associated with existence of pressure ulcers (PUs) and the effect on survival from the time of admission. Patients admitted to the Skilled Nursing Department of the Herzog Hospital, Jerusalem, between 1 July 2008 and 31 December 2011. Of the 174 admitted patients (mean age: 77·4 ± 13·2 years), 107 (61·5%) had pre-existing PUs and 67 (38·5%) did not have PUs. Major systemic factors were assessed for each patient at the time of admission: sociodemographic characteristics, comorbidities, use of urinary catheter, tube feeding and tracheostomy; nutritional state; Global Deterioration Scale, Glasgow Coma Scale and Norton Scale. Complications such as the number of provided antibiotic courses, and length and outcomes of hospitalisation were identified at the end of the study. In the univariate analysis, patients in the PU group had significantly prevalent characteristics including advanced age, low cognitive and consciousness function, low Norton scale, Parkinson's disease and anaemia due to chronic diseases, low nutritional parameters and higher number of antibiotics provided. Conditions that were associated with PUs in multiple regression analyses included advanced dementia (OR = 3·0, 95% CI: 1·4-6·3; P = 0·002), urinary catheter usage (OR = 2·25, 95% CI: 1·06-4·7; P = 0·03), low body mass index, BMI (OR = 0·92, 95% CI: 0·86-0·99; P = 0·02) and anaemia level (OR = 0·7, 95% CI: 0·58-0·9; P = 0·004). The median survival time of patients with PUs was significantly lower than the non PUs group (94 versus 414 days, respectively) (P = 0·005, log rank test). Length of stay was also significantly lower in the PU group (166 versus 270 days, P = 0·02). The existence of PUs may indicate a final common pathway of various systemic factors (geriatric conditions, diseases and frailty dysfunction).

Pressure ulcers: Back to the basics

Pressure ulcer in an otherwise sick patient is a matter of concern for the care givers as well as the medical personnel. A lot has been done to understand the disease process. So much so that USA and European countries have established advisory panels in their respective continents. Since the establishment of these organizations, the understanding of the pressure ulcer has improved significantly. The authors feel that the well documented and well publicized definition of pressure ulcer is somewhat lacking in the correct description of the disease process. Hence, a modified definition has been presented. This disease is here to stay. In the process of managing these ulcers the basic pathology needs to be understood well. Pressure ischemia is the main reason behind the occurrence of ulceration. Different extrinsic and intrinsic factors have been described in detail with review of literature. There are a large number of risk factors causing ulceration. The risk assessment scales have eluded the surgical literature and mostly remained in nursing books and websites. These scales have been reproduced for completion of the basics on decubitus ulcer. The classification of the pressure sores has been given in a comparative form to elucidate that most of the classifications are the same except for minor variations. The management of these ulcers is ever evolving but the age old saying of "prevention is better than cure" suits this condition the most.

A national prevalence study of pressure ulcers in French hospital inpatients

OBJECTIVE

To ascertain pressure ulcer prevalence rate in French hospitals.

METHOD

In 2004, a cross-sectional study was conducted in all French hospitals, except university hospitals. The National Pressure Ulcer Advisory Panel (NPUAP) staging was used. Data were collected using two self-administered questionnaires.

RESULTS

A total of 37,307 inpatients in 1170 wards in 1149 hospitals were assessed, representing a response rate of 93.5%. Their mean age was 72.3 years and 62% were females. In all, 3314 patients had at least one pressure ulcer, giving a prevalence rate of 8.9%. A total of 4991 pressure ulcers were recorded; 64% of the patients had only one pressure ulcer. Fifty-five per cent of the patients had at least two concomitant diseases. When patients with only one ulcer were assessed, the most common locations were the heels (53%) and sacrum (29%). Heel pressure ulcers were more common in patients with obliterative arterial disease, and sacral pressure ulcers were more frequent in incontinent (urine, faecal and double incontinence) patients. Patients with multiple pressure ulcers had more severe lesions.

CONCLUSION

These results indicate that the prevalence of pressure ulcers in French hospital inpatients has remained stable since the last prevalence study undertaken 10 years before, when the rate was 8.9%. Such studies should be encouraged in all health-care settings as a means of improving the care provided.

Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept

Geriatricians have embraced the term "geriatric syndrome," using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors-older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility-were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.