Pressure ulcer risk assessment in long-term care nursing

Improving practice and informing policy development: The impact of gerontological nursing research

Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.

Pressure ulcers in Jordan: a snapshot survey of a tertiary public hospital

BACKGROUND

Patients are at risk of developing pressure ulcers while they are hospitalised. These risks need to be managed effectively to avoid harm and to minimise costs.

OBJECTIVE

This study was aimed at determining the prevalence and incidence of pressure ulcers at selected acute clinical settings in central Jordan.

DESIGN

A cross-sectional survey design.

METHOD

An inpatient snapshot survey was conducted over 4 weeks in the two medical wards in a tertiary public hospital.

RESULTS

190 participants were surveyed, 30 cases were identified, 53% were male, and 75% were aged 60 years or older. Prevalence was 24%, approximately half of the cases were grade 2 and 23% were grade 3 and 4. Pressure ulcers were mainly found on the sacrum (43%), followed by the heel (24%). Over 4 weeks, 29 new pressure ulcer cases were identified; 55% were male, and 90% were aged 60 years or older. Pressure ulcers were mainly-in 38% of cases-identified with cerebral vascular accident patients.

CONCLUSION

The results of the snapshot survey confirmed that there is a problem with maintaining patients' safety in terms of patients acquiring pressure ulcers in hospital. The number of pressure ulcers indicate less-than-optimal management of patient safety, which requires a more detailed investigation.

A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled trial

BACKGROUND

Frail older people admitted to nursing homes are at risk of a range of adverse outcomes, including pressure ulcers. Clinical decision support systems are believed to have the potential to improve care and to change the behaviour of healthcare professionals.

OBJECTIVES

To determine whether a multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention improves adherence to recommendations for pressure ulcer prevention in nursing homes.

DESIGN

Two-armed randomized controlled trial in a nursing home setting in Belgium. The trial consisted of a 16-week implementation intervention between February and June 2010, including one baseline, four intermediate, and one post-testing measurement. Primary outcome was the adherence to guideline-based care recommendations (in terms of allocating adequate pressure ulcer prevention in residents at risk). Secondary outcomes were the change in resident outcomes (pressure ulcer prevalence) and intermediate outcomes (knowledge and attitudes of healthcare professionals).

SETTING

Random sample of 11 wards (6 experimental; 5 control) in a convenience sample of 4 nursing homes in Belgium.

PARTICIPANTS

In total, 464 nursing home residents and 118 healthcare professionals participated.

METHODS

The experimental arm was involved in a multi-faceted tailored implementation intervention of a clinical decision support system, including interactive education, reminders, monitoring, feedback and leadership. The control arm received a hard-copy of the pressure ulcer prevention protocol, supported by standardized 30 min group lecture.

RESULTS

Patients in the intervention arm were significantly more likely to receive fully adequate pressure ulcer prevention when seated in a chair (F=16.4, P=0.003). No significant improvement was observed on pressure ulcer prevalence and knowledge of the professionals. While baseline attitude scores were comparable between both groups [exp. 74.3% vs. contr. 74.5% (P=0.92)], the mean score after the intervention was 83.5% in the experimental group vs. 72.1% in the control group (F=15.12, P<0.001).

CONCLUSION

The intervention was only partially successful to improve the primary outcome. Attitudes improved significantly while the knowledge of the healthcare workers remained unsatisfactorily low. Further research should focus on the underlying reasons for these findings.

A pressure ulcer prevention programme specially designed for nursing homes: does it work?

AIM

The aim of this study was to evaluate a pressure ulcer prevention programme for nursing homes to ascertain the feasibility of its implementation, impact on care staff and outcomes for pressure ulcer knowledge and skills and pressure ulcer reduction.

BACKGROUND

No pressure ulcer prevention protocol for long-term care settings has been established to date. The first author of this study thus developed a pressure ulcer prevention programme for nursing homes.

DESIGN

A quasi-experimental pretest and post-test design was adopted.

METHODS

Forty-one non-licensed care providers and eleven nurses from a government-subsidised nursing home voluntarily participated in the study. Knowledge and skills of the non-licensed care providers were assessed before, immediately after and six weeks after the training course, and pressure ulcer prevalence and incidence were recorded before and during the protocol implementation. At the end of the programme implementation, focus group interviews with the subjects were conducted to explore their views on the programme.

RESULTS

A statistically significant improvement in knowledge and skills scores amongst non-licensed care providers was noted. Pressure ulcer prevalence and incidence rates dropped from 9-2·5% and 2·5-0·8%, respectively, after programme implementation. The focus group findings indicated that the programme enhanced the motivation of non-licensed care providers to improve their performance of pressure ulcer prevention care and increased communication and cooperation amongst care staff, but use of the modified Braden scale was considered by nurses to increase their workload.

CONCLUSION

A pressure ulcer prevention programme for nursing homes, which was feasible and acceptable, with positive impact and outcome in a nursing home was empirically developed.

RELEVANCE TO CLINICAL PRACTICE

The study findings can be employed to modify the programme and its outcomes for an evaluation of effectiveness of the programme through a randomised controlled trial.

Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison

AIM

Comparison of the diagnostic accuracy of two pressure ulcer risk assessment scales and one generic nursing assessment tool.

BACKGROUND

Guidelines for pressure ulcer prevention recommend an initial risk screening of all patients, followed by appropriate nursing interventions. Additionally, personal and financial resources have to be allocated carefully to avoid excessive or too little treatment. Risk assessments should be accurate and applicable, and some studies showed that generic nursing tools also provide specific information for nursing diagnoses, like risk for pressure ulcer.

DESIGN

Cross sectional observational study.

METHODS

A total of 1053 adult patients of a university hospital in Germany were investigated. For each patient, the Braden Scale, the Waterlow Scale and the Care Dependency Scale were completed. A skin inspection was conducted by trained nurses. Correlations between the three scales and the mean values of each pressure ulcer risk assessment scales for each Care Dependency Scale value were calculated. To determine the association between susceptibility to pressure ulcer and observed pressure ulcer, the area under the curve was calculated.

RESULTS

There was a higher correlation between the Braden Scale and the Care Dependency Scale (r = 0.82) than between the two pressure ulcer risk assessment scales (-0.65). The highest area under the curve was reached by the Braden Scale (0.86), followed by the Care Dependency Scale (0.83) and the Waterlow Scale (0.81). Only the Braden Scale (cut-off 18) and the Care Dependency Scale (cut-off 65) reached the psychometric requirements of at least 70% sensitivity and 70% specificity.

CONCLUSIONS

The Care Dependency Scale could be used for both a general nursing assessment and as a screening tool for risk for pressure ulcers. The Braden Scale showed the highest association with the occurrence of pressure ulcer.

RELEVANCE TO CLINICAL PRACTICE

The Care Dependency Scale is a useful screening tool to identify patients at risk for pressure ulcers. Nursing assessment activities might be reduced by using a generic nursing assessment tool also for specific risk screening.

Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings

Background

In long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention.

Methods

Data for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients.

Results

A data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer.

Conclusions

interRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Do pressure ulcer risk assessment scales improve clinical practice?

Standardized assessment instruments are deemed important for estimating pressure ulcer risk. Today, more than 40 so-called pressure ulcer risk assessment scales are available but still there is an ongoing debate about their usefulness. From a measurement point of view pressure ulcer (PU) risk assessment scales have serious limitations. Empirical evidence supporting the validity of PU risk assessment scale scores is weak and obtained scores contain varying amounts of measurement error. The concept of pressure ulcer risk is strongly related to the general health status and severity of illness. A clinical impact due do the application of these scales could also not be demonstrated. It is questionable whether completion of standardized pressure ulcer risk scales in clinical practice is really needed.

Pressure ulcer risk assessment in critical care: interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units

BACKGROUND

The application of standardized pressure ulcer risk assessment scales is recommended in clinical practice.

OBJECTIVES

The aims of this study were to compare the interrater reliabilities of the Braden and Waterlow scores and subjective pressure ulcer risk assessment and to determine the construct validity of these three assessment approaches.

DESIGN

Observational.

SETTINGS

Two intensive care units of a large University Hospital in Germany.

PARTICIPANTS

21 and 24 patients were assessed by 53 nurses. Patients' mean age was 69.7 (SD 8.3) and 67.2 (SD 11.3).

METHODS

Two interrater reliability studies were conducted. Samples of patients were assessed independently by a sample of three nurses. A 10-cm visual analogue scale was applied to measure subjective pressure ulcer risk rating. Intraclass correlation coefficients (ICC) and standard errors of measurement (SEM) were used to determine interrater reliability and agreement of the item and sum scores. Pearson product moment correlation coefficients (r) were used to indicate the degree and direction of the relationships between the measures.

RESULTS

The interrater reliability for the subjective pressure ulcer risk assessment was ICC(1,1)=0.51 (95% CI 0.26-0.74) and 0.71 (95% CI 0.53-0.85). Interrater reliability of Braden scale sum scores was ICC(1,1)=0.72 (95% CI 0.52-0.87) and 0.84 (95% CI 0.72-0.92) and for Waterlow scale sum scores ICC(1,1)=0.36 (95% CI 0.09-0.63) and 0.51 (95% CI 0.27-0.72). The absolute degree of correlation between the measures ranged from 0.51 to 0.77.

CONCLUSIONS

Interrater reliability coefficients indicate a high degree of measurement error inherent in the scores. Compared to subjective risk assessment and the Waterlow scale scores the Braden scale performed best. However, measurement error is too high to draw valid inferences for individuals. Less than 26-59% of variances in scores of one scale were determined by scores of another scale indicating that all three instruments only partly measured the same construct. The use of the Braden-, Waterlow- and Visual Analogue scales for measuring pressure ulcer risk of intensive care unit patients is not recommended.

Predicting posthospital recovery of physical function among older adults after lower extremity surgery in a short-stay skilled nursing facility

This study describes the posthospital recovery of physical function among 131 older adults after lower extremity surgery in a short-stay skilled nursing facility (SNF), and identifies admission factors predicting physical function at discharge. Multiple regression analyses found that older adults with low baseline physical function, pressure ulcer, malnutrition, memory loss upon admission, and not enough physical therapy had poor physical function at the time of discharge from the facility. This study generated the following recommendations for nurses working in short-stay SNFs: (1) screen all posthospital residents at admission with predictors to identify people at risk for physical functional decline, (2) design and implement targeted nursing and rehabilitation interventions to improve physical function, and (3) develop discharge plans that provide ongoing monitoring and interventions for community or nursing home nurses.

Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement

AIMS AND OBJECTIVES

To consider the validity and reliability of risk assessment scales for pressure ulcers.

BACKGROUND

Pressure ulcers are a major problem worldwide. They cause morbidity and lead to mortality. Risk assessment scales have been available for nearly 50 years, but there is insufficient evidence to state with any certainty that they are useful.

DESIGN

A literature review and commentary.

METHODS

Bibliographic databases were searched for relevant papers, a critical review was completed on relevant papers.

RESULTS

There is contradictory evidence concerning the validity of risk assesment scales. The interaction of education, clinical judgement and use of risk assessment scales has not been fully explored. It is not known which of these is most important, nor whether combining them results in better patient care.

CONCLUSIONS

There is a need for further work. A study exploring the complex interaction of risk assessment scales, clinical judgement and education and training is introduced.

RELEVANCE TO CLINICAL PRACTICE

Nurses may be wasting their time conducting risk assessment scoring if clinical judgement and/or education are sufficient to assess pressure ulcers risk.

The Norton, Waterlow, Braden, and Care Dependency ScalesL Comparing Their Validity When Identifying Patients' Pressure Sore Risk

OBJECTIVES

We compared the sensitivity and specificity of the Norton, Waterlow, and Braden Scales in identifying patients at pressure sore risk. An additional goal was to determine whether or not the Care Dependency Scale (CDS) is able to detect patients at risk for pressure sore development.

METHODS

The investigation was part of a prevalence study involving 754 patients in 3 Berlin hospitals. A questionnaire was used containing the subscales of the 3 risk calculators (Norton, Waterlow, and Braden), and the CDS. On the specified day nurses filled in the questionnaire using data obtained from the patients' charts and direct visualization of the patients' skin.

RESULTS

Thirty-four out of 754 patients had at least 1 pressure ulcer. Comparing the 3 risk assessment tools, the Waterlow scale demonstrated the highest sensitivity (0.86) and the Norton scale demonstrated the highest specificity (0.75). Individuals with pressure sores were more likely to be care dependent (t-test: P< .01); 27 of them had a CDS score lower than 55. Using the score of 55 as the cut-off point, the CDS demonstrated a sensitivity of 0.74 and a specificity of 0.83.

SUMMARY

This study demonstrated remarkable differences among the 3 commonly used risk assessment tools, in regards to sensitivity and specificity. Moreover, the CDS seems to have a diagnostic value similar to the 3 commonly used risk assessment calculators.

Wound care for elderly patients: advances and clinical applications for practicing physicians

Chronic ulcers (wounds) are commonly encountered in medical practice, particularly in elderly patients who have chronic medical conditions. Health care providers must be adept at diagnosing chronic ulcers and optimizing medical treatment. We describe the best medical practice for the 4 common types of chronic ulcers: pressure ulcers, ischemic ulcers, venous ulcers, and neuropathic ulcers. We emphasize the importance of nutrition and proper wound care as a foundation for the management of all chronic ulcers. There is a unique therapeutic goal for each chronic ulcer. Pressure relief should be provided for both pressure ulcers and neuropathic ulcers. Ischemic ulcers require revascularization. Patients with venous ulcers need adequate edema control. We outline advances in each of these areas and discuss the newest developments in wound care, including growth factors, hyperbaric oxygen, and vacuum-assisted devices. Chronic ulcers in elderly patients can heal with proper diagnosis and good medical care.