Iatrogenesis in the elderly. Impaired skin integrity

Pilot study on benefits of applying a hot towel for 10 s to the skin of elderly nursing home residents during bed baths: Towards safe and comfortable bed baths

This study examined the effects of applying a hot towel to the skin of elderly people for 10 s (AHT10s) during a bed bath. We hypothesized from our previous studies that AHT10s would increase the stratum corneum water content and improve the skin barrier function of the elderly and invited residents (n = 21) of long-term care facilities to participate in this crossover study. Each participant received a bed bath with AHT10s and also a bed bath without hot towel application. The stratum corneum water content and transepidermal water loss (TEWL) were measured during bed bathing sessions and the experience was subjectively evaluated by participants. The TEWL increased significantly when bed bath did not involve AHT10s, but there was no such significant increase when AHT10s was performed. AHT10s also raised the skin surface temperature and provided warmth and comfort to all participants. These results suggest that, in the target population, AHT10s will lead to TEWL advantages and provide warmth and comfort.

Validating administrative data for the detection of adverse events in older hospitalized patients

Older hospitalized patients are at risk of experiencing adverse events including, but not limited to, hospital-acquired pressure ulcers, fall-related injuries, and adverse drug events. A significant challenge in monitoring and managing adverse events is lack of readily accessible information on their occurrence.

PURPOSE

The objective of this retrospective cross-sectional study was to validate diagnostic codes for pressure ulcers, fall-related injuries, and adverse drug events found in routinely collected administrative hospitalization data.

METHODS

All patients 65 years of age or older discharged between April 1, 2009 and March 31, 2011 from a provincial academic health sciences center in Canada were eligible for inclusion in the validation study. For each of the three types of adverse events, a random sample of 50 patients whose records were positive and 50 patients whose records were not positive for an adverse event was sought for review in the validation study (n=300 records in total). A structured health record review was performed independently by two health care providers with experience in geriatrics, both of whom were unaware of the patient's status with respect to adverse event coding. A physician reviewed 40 records (20 reviewed by each health care provider) to establish interrater agreement.

RESULTS

A total of 39 pressure ulcers, 56 fall-related injuries, and 69 adverse drug events were identified through health record review. Of these, 34 pressure ulcers, 54 fall-related injuries, and 47 adverse drug events were also identified in administrative data. Overall, the diagnostic codes for adverse events had a sensitivity and specificity exceeding 0.67 (95% confidence interval [CI]: 0.56-0.99) and 0.89 (95% CI: 0.72-0.99), respectively.

CONCLUSION

It is feasible and valid to identify pressure ulcers, fall-related injuries, and adverse drug events in older hospitalized patients using routinely collected administrative hospitalization data. The information is relatively inexpensive and easy to access with no impact on clinical staff.

Development of a modularized seating system to actively manage interface pressure

Pressure ulcers can be a fatal complication. Many immobile wheelchair users face this threat. Current passive and active cushions do reduce the incidence of pressure ulcers and they have different merits. We proposed an active approach to combine their advantages which is based on the concept that the interface pressure can be changed with different supporting shapes. The purpose of this paper is to verify the proposed approach. With practical applications in mind, we have developed a modular system whose support surface is composed by height-adjustable support elements. Each four-element module was self-contained and composed of force sensors, position sensors, linear actuators, signal conditioners, driving circuits, and signal processors. The modules could be chained and assembled together easily to form different-sized support surfaces. Each support element took up a 3 cm × 3 cm supporting area. The displacement resolution was less than 0.1 mm and the force sensor error was less than 1% in the 2000 g range. Each support element of the system could provide 49 N pushing force (408 mmHg over the 3 cm × 3 cm area) at a speed of 2.36 mm/s. Several verification tests were performed to assess the whole system's feasibility. Further improvements and clinical applications were discussed. In conclusion, this modularized system is capable of actively managing interface pressure in real time.

Cohort study of atypical pressure ulcers development

Atypical pressure ulcers (APU) are distinguished from common pressure ulcers (PU) with both unusual location and different aetiology. The occurrence and attempts to characterise APU remain unrecognised. The purpose of this cohort study was to analyse the occurrence of atypical location and the circumstances of the causation, and draw attention to the prevention and treatment by a multidisciplinary team. The cohort study spanned three and a half years totalling 174 patients. The unit incorporates two weekly combined staff meetings. One concentrates on wound assessment with treatment decisions made by the physician and nurse, and the other, a multidisciplinary team reviewing all patients and coordinating treatment. The main finding of this study identified APU occurrence rate of 21% within acquired PU over a three and a half year period. Severe spasticity constituted the largest group in this study and the most difficult to cure wounds, located in medial aspects of knees, elbows and palms. Medical devices caused the second largest occurrence of atypical wounds, located in the nape of the neck, penis and nostrils. Bony deformities were the third recognisable atypical wound group located in shoulder blades and upper spine. These three categories are definable and time observable. APU are important to be recognisable, and can be healed as well as being prevented. The prominent role of the multidisciplinary team is primary in identification, prevention and treatment.

Clinical skin temperature measurement to predict incipient pressure ulcers

OBJECTIVE

To evaluate temperature differences between areas of erythema and surrounding healthy tissue to determine whether clinical temperature measurement of sites at risk for pressure ulcer development could be used to indicate tissue damage. To validate the temperature portion of the National Pressure Ulcer Advisory Panel's new Stage I pressure ulcer definition.

DESIGN

Repeated measures design.

SETTING

Acute rehabilitation hospital.

SUBJECTS

65 outpatients and inpatients presenting with pressure-induced erythema at areas at risk for pressure ulcer development. The subjects were primarily non-ambulatory and exhibited a range of skin pigmentation and disabilities, including spinal injury, multiple sclerosis, and lower-limb amputations.

MAIN RESULTS

The temperature and appearance of 80 pairs of erythematic and control sites were documented. Sites were considered to have equal temperatures if the difference was within plus or minus 1.0 degree F. Fifteen percent (n = 12) of the erythematic sites were the same temperature as the surrounding tissue, 23% (n = 18) of the erythematic sites were cooler than the control sites, and 63% (n = 50) were warmer.

CONCLUSION

Both increased and decreased temperature differences can be used to indicate reactive hyperemia or a Stage I pressure ulcer, but a tissue integrity problem may still exist despite the absence of a temperature difference.

Pressure ulcer risk assessment in long-term care nursing

The intent of this study was to determine whether the typical practice of using risk assessment tools in combination with the federally mandated Minimum Data Set (MDS) actually predict more cases of pressure ulcers (PUs) in long-term care facilities. Data in this study were collected from 555 resident charts in a sample of eight nursing homes. A total of 66 PUs were identified between September 1, 1996 and September 1, 1997 in a comparative test of the predictive abilities of the MDS versus the Braden Scale (BS) patient profiles. As shown by a Chi square test, the MDS and the BS assessment tools were valid in finding factors that placed residents in jeopardy of developing pressure ulcers: MDS chi 2 = 43.68, df = 1, p < .0001 and BS chi 2 = 52.47, df = 1, p < .001. However, a two-tailed t test, indicated results of the BS were significantly different than the MDS: t = 3.77, df = 97, p < .003 and BS = t = 3.77, df = 97, p < .001. Both the MDS and the BS identified patient factors: the MDS identified 311 at risk, resulting in accurate prediction of 62 of 66 PUs, while the BS found 172 at risk and predicted only 46 PUs accurately. Therefore, data indicate the BS did not make a significant difference in predicting the incidence of pressure ulcers in this sample of long-term care facilities. These unexpected findings would argue in favor of discontinuing the practice of using the BS for PU risk assessment simultaneously with the MDS, but rather at independent time frames such as immediately upon resident admission. This would continue to support the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP), and at the same time, provide a more timely pressure ulcer risk assessment.

The effects of psyllium hydrophilic mucilloid on diarrhea in enterally fed patients

OBJECTIVE

To investigate the efficacy of psyllium hydrophilic mucilloid (PHM) for prevention of diarrhea and to compare methods of PHM delivery.

DESIGN

Experimental.

SETTING

University-affiliated Department of Veterans Affairs Medical Center.

SUBJECTS

Sixty patients from medical-surgical and intensive care units who received newly initiated enteral feeding via feeding tube.

OUTCOME MEASURES

Diarrhea, stool frequency and consistency, and feeding tube obstruction.

INTERVENTION

Receipt of PHM (7 gm, twice-daily) added to continuous feeding or given as a bolus with intermittent feeding, or receipt of No PHM for 7 days after initiation of enteral feeding.

RESULTS

Fifteen subjects (25%) developed diarrhea (defined as 3 or more liquid stools per day, or 2 or more liquid stools on successive days). There were no significant differences in incidence of diarrhea or percentage of days of diarrhea between subjects who did and did not receive PHM. However, subjects who received PHM in their continuous feedings had a significantly higher number of gelatinous stools, and the combined PHM groups had a significantly lower number of liquid stools and a higher number of normal stools than did subjects who did not receive PHM. For the combined PHM groups, there was a 12% incidence of small-bore feeding tube occlusion--requiring replacement.

CONCLUSIONS

Further study with a larger sample is necessary to evaluate trends found in this pilot study and to determine PHM efficacy for prevention of diarrhea. PHM administration may result in small-bore feeding tube obstruction, and thus requires adequate dilution and close monitoring.