Tube feeding in patients with advanced dementia: a review of the evidence

Patients with advanced dementia frequently develop eating difficulties and weight loss. Enteral feeding tubes are often used in this situation, yet benefits and risks of this therapy are unclear. We searched MEDLINE, 1966 through March 1999, to identify data about whether tube feeding in patients with advanced dementia can prevent aspiration pneumonia, prolong survival, reduce the risk of pressure sores or infections, improve function, or provide palliation. We found no published randomized trials that compare tube feeding with oral feeding. We found no data to suggest that tube feeding improves any of these clinically important outcomes and some data to suggest that it does not. Further, risks are substantial. The widespread practice of tube feeding should be carefully reconsidered, and we believe that for severely demented patients the practice should be discouraged on clinical grounds.

Preventing pressure ulcers: a systematic review

CONTEXT

Pressure ulcers are common in a variety of patient settings and are associated with adverse health outcomes and high treatment costs.

OBJECTIVE

To systematically review the evidence examining interventions to prevent pressure ulcers.

DATA SOURCES AND STUDY SELECTION

MEDLINE, EMBASE, and CINAHL (from inception through June 2006) and Cochrane databases (through issue 1, 2006) were searched to identify relevant randomized controlled trials (RCTs). UMI Proquest Digital Dissertations, ISI Web of Science, and Cambridge Scientific Abstracts were also searched. All searches used the terms pressure ulcer, pressure sore, decubitus, bedsore, prevention, prophylactic, reduction, randomized, and clinical trials. Bibliographies of identified articles were further reviewed.

DATA SYNTHESIS

Fifty-nine RCTs were selected. Interventions assessed in these studies were grouped into 3 categories, ie, those addressing impairments in mobility, nutrition, or skin health. Methodological quality for the RCTs was variable and generally suboptimal. Effective strategies that addressed impaired mobility included the use of support surfaces, mattress overlays on operating tables, and specialized foam and specialized sheepskin overlays. While repositioning is a mainstay in most pressure ulcer prevention protocols, there is insufficient evidence to recommend specific turning regimens for patients with impaired mobility. In patients with nutritional impairments, dietary supplements may be beneficial. The incremental benefit of specific topical agents over simple moisturizers for patients with impaired skin health is unclear.

CONCLUSIONS

Given current evidence, using support surfaces, repositioning the patient, optimizing nutritional status, and moisturizing sacral skin are appropriate strategies to prevent pressure ulcers. Although a number of RCTs have evaluated preventive strategies for pressure ulcers, many of them had important methodological limitations. There is a need for well-designed RCTs that follow standard criteria for reporting nonpharmacological interventions and that provide data on cost-effectiveness for these interventions.

The cost of pressure ulcers in the UK

OBJECTIVE

To estimate the annual cost of treating pressure ulcers in the UK.

DESIGN

Costs were derived from a bottom-up methodology, based on the daily resources required to deliver protocols of care reflecting good clinical practice.

SETTING

Health and social care system in the UK.

SUBJECTS

Patients developing a pressure ulcer.

METHODS

A bottom-up costing approach is used to estimate treatment cost per episode of care and per patient for ulcers of different grades and level of complications. Also, total treatment cost to the health and social care system in the UK.

RESULTS

The cost of treating a pressure ulcer varies from pound 1,064 (Grade 1) to pound 10,551 (Grade 4). Costs increase with ulcer grade because the time to heal is longer and because the incidence of complications is higher in more severe cases. The total cost in the UK is pound 1.4- pound 2.1 billion annually (4% of total NHS expenditure). Most of this cost is nurse time.

CONCLUSIONS

Pressure ulcers represent a very significant cost burden in the UK. Without concerted effort this cost is likely to increase in the future as the population ages. To the extent that pressure ulcers are avoidable, pressure damage may be indicative of clinical negligence and there is evidence that litigation could soon become a significant threat to healthcare providers in the UK, as it is in the USA.

Risk assessment scales for pressure ulcer prevention: a systematic review

AIM

This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer.

BACKGROUND

Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation.

METHOD

A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review.

FINDINGS

Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75).

CONCLUSION

There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.

Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes

CONTEXT

The association of an adult tele-intensive care unit (ICU) intervention with hospital mortality, length of stay, best practice adherence, and preventable complications for an academic medical center has not been reported.

OBJECTIVE

To quantify the association of a tele-ICU intervention with hospital mortality, length of stay, and complications that are preventable by adherence to best practices.

DESIGN, SETTING, AND PATIENTS

Prospective stepped-wedge clinical practice study of 6290 adults admitted to any of 7 ICUs (3 medical, 3 surgical, and 1 mixed cardiovascular) on 2 campuses of an 834-bed academic medical center that was performed from April 26, 2005, through September 30, 2007. Electronically supported and monitored processes for best practice adherence, care plan creation, and clinician response times to alarms were evaluated.

MAIN OUTCOME MEASURES

Case-mix and severity-adjusted hospital mortality. Other outcomes included hospital and ICU length of stay, best practice adherence, and complication rates.

RESULTS

The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the preintervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio [OR], 0.40 [95% CI, 0.31-0.52]). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis (99% vs 85%, respectively; OR, 15.4 [95% CI, 11.3-21.1]) and prevention of stress ulcers (96% vs 83%, respectively; OR, 4.57 [95% CI, 3.91-5.77], best practice adherence for cardiovascular protection (99% vs 80%, respectively; OR, 30.7 [95% CI, 19.3-49.2]), prevention of ventilator-associated pneumonia (52% vs 33%, respectively; OR, 2.20 [95% CI, 1.79-2.70]), lower rates of preventable complications (1.6% vs 13%, respectively, for ventilator-associated pneumonia [OR, 0.15; 95% CI, 0.09-0.23] and 0.6% vs 1.0%, respectively, for catheter-related bloodstream infection [OR, 0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs 13.3 days, respectively; hazard ratio for discharge, 1.44 [95% CI, 1.33-1.56]). The results for medical, surgical, and cardiovascular ICUs were similar.

CONCLUSION

In a single academic medical center study, implementation of a tele-ICU intervention was associated with reduced adjusted odds of mortality and reduced hospital length of stay, as well as with changes in best practice adherence and lower rates of preventable complications.

Systematic Review of Studies of Staffing and Quality in Nursing Homes

PURPOSE

To evaluate a range of staffing measures and data sources for long-term use in public reporting of staffing as a quality measure in nursing homes.

METHOD

Eighty-seven research articles and government documents published from 1975 to 2003 were reviewed and summarized. Relevant content was extracted and organized around 3 themes: staffing measures, quality measures, and risk adjustment variables. Data sources for staffing information were also identified.

RESULTS

There is a proven association between higher total staffing levels (especially licensed staff) and improved quality of care. Studies also indicate a significant relationship between high turnover and poor resident outcomes. Functional ability, pressure ulcers, and weight loss are the most sensitive quality indicators linked to staffing. The best national data sources for staffing and quality include the Minimum Data Set (MDS) and On-line Survey and Certification Automated Records (OSCAR). However, the accuracy of this self-reported information requires further reliability and validity testing.

CONCLUSIONS

A nationwide instrument needs to be developed to accurately measure staff turnover. Large-scale studies using payroll data to measure staff retention and its impact on resident outcomes are recommended. Future research should use the most nurse-sensitive quality indicators such as pressure ulcers, functional status, and weight loss.

Correlation of pressure sores and nutritional status

As life expectancy increases, so do the problems of the elderly population. One major problem is that of protein calorie malnutrition; another is the susceptibility of this population to pressure sores. The purpose of this study was to determine if a correlation exists between deteriorating nutritional status and the development of pressure sores. The nutritional status of 232 nursing home patients (mean age 72.9 +/- 12 years) was determined using biochemical and anthropometric measurements. Overall, the incidence of some degree of malnutrition was 59%. Seventeen of the patients were found to have pressure sores and were all malnourished. When classified as mild, moderate, or severe malnutrition, the patients with pressure sores were in the severe group. There was a significant difference (P less than .001) between the nutritional status of pressure sore patients and the malnourished patients. It appears that the development of pressure sores correlates with nutritional deficiencies. The authors' findings suggest a need for more aggressive nutritional support in the elderly, especially those with pressure sores.

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

OBJECTIVE

To compare quality of care in for-profit and not-for-profit nursing homes.

DESIGN

Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes.

RESULTS

A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17).

CONCLUSIONS

This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

Practice-Based Evidence Study Design for Comparative Effectiveness Research

OBJECTIVES

To describe a new, rigorous, comprehensive practice-based evidence for clinical practice improvement (PBE-CPI) study methodology, and compare its features, advantages, and disadvantages to those of randomized controlled trials and sophisticated statistical methods for comparative effectiveness research.

RESEARCH DESIGN

PBE-CPI incorporates natural variation within data from routine clinical practice to determine what works, for whom, when, and at what cost. It uses the knowledge of front-line caregivers, who develop study questions and define variables as part of a transdisciplinary team. Its comprehensive measurement framework provides a basis for analyses of significant bivariate and multivariate associations between treatments and outcomes, controlling for patient differences, such as severity of illness.

RESULTS

PBE-CPI studies can uncover better practices more quickly than randomized controlled trials or sophisticated statistical methods, while achieving many of the same advantages. We present examples of actionable findings from PBE-CPI studies in postacute care settings related to comparative effectiveness of medications, nutritional support approaches, incontinence products, physical therapy activities, and other services.

CONCLUSIONS

Outcomes improved when practices associated with better outcomes in PBE-CPI analyses were adopted in practice.

Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis

BACKGROUND

There have been few systematic reviews and no meta-analyses of the clinical benefits of nutritional support in patients with, or at risk of developing, pressure ulcers. Therefore, this systematic review and meta-analysis was undertaken to address the impact of enteral nutritional support on pressure ulcer incidence and healing and a range of other clinically relevant outcome measures in this group.

METHODS

Fifteen studies (including eight randomised controlled trials (RCTs)) of oral nutritional supplements (ONS) or enteral tube feeding (ETF), identified using electronic databases (including Pub Med and Cochrane) and bibliography searches, were included in the systematic review. Outcomes including pressure ulcer incidence, pressure ulcer healing, quality of life, complications, mortality, anthropometry and dietary intake were recorded, with the aim of comparing nutritional support versus routine care (e.g. usual diet and pressure ulcer care) and nutritional formulas of different composition. Of these 15 studies, 5 RCTs comparing ONS (4 RCTs) and ETF (1 RCT) with routine care could be included in a meta-analysis of pressure ulcer incidence.

RESULTS

Meta-analysis showed that ONS (250-500 kcal, 2-26 weeks) were associated with a significantly lower incidence of pressure ulcer development in at-risk patients compared to routine care (odds ratio 0.75, 95% CI 0.62-0.89, 4 RCTs, n=1224, elderly, post-surgical, chronically hospitalised patients). Similar results were obtained when a combined meta-analysis of ONS (4 RCT) and ETF (1 RCT) trials was performed (OR 0.74, 95% CI 0.62-0.88, 5 RCTs, n=1325). Individual studies showed a trend towards improved healing of existing pressure ulcers with disease-specific (including high protein) versus standard formulas, although robust RCTs are required to confirm this. Although some studies indicate that total nutritional intake is improved, data on other outcome measures (quality of life) are lacking.

CONCLUSIONS

This systematic review shows enteral nutritional support, particularly high protein ONS, can significantly reduce the risk of developing pressure ulcers (by 25%). Although studies suggest ONS and ETF may improve healing of PU, further research to confirm this trend is required.

Pressure ulcers in intensive care patients: a review of risks and prevention

OBJECTIVE

Review of the literature concerning pressure ulcers in the intensive care setting. DATA SOURCE AND STUDY SELECTIONS: Computerized databases (Medline from 1980 until 1999 and CINAHL from 1982 until 1999). The indexing terms for article retrieval were: "pressure ulcers", "pressure sores", "decubitus", and "intensive care". Nineteen articles met the selection criteria, and seven more were found from the references of these articles. One thesis was also analyzed.

RESULTS

Data on prevention, incidence, and costs of pressure ulcers in ICU patients are scarce. Overall there are no conclusive studies on the identification of pressure ulcer risk factors. None of the existing risk-assessment scales was developed especially for use in ICU patients. It is highly questionable to what extent these scales can be used in this setting as they are not even reliable in "standard care". The following risk factors might play a role in pressure ulcer development: duration of surgery and number of operations, fecal incontinence and/or diarrhea, low preoperative protein and albumin concentrations, disturbed sensory perception, moisture of the skin, impaired circulation, use of inotropic drugs, diabetes mellitus, too unstable to turn, decreased mobility, and high APACHE II score. The number of patients per study ranged from 5 from 638. The definition of "pressure ulcer" varied widely between authors or was not mentioned.

CONCLUSIONS

Meaningful comparison cannot be made between the various studies because of the use of different grading systems for pressure ulcers, different methods of data collection, different (or lack of) population characteristics, unreported preventive measures, and the use of different inclusion and exclusion criteria. There is a need for well-conducted studies covering all these aspects.

The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers

BACKGROUND

Turning is considered to be an effective way of preventing pressure ulcers, however almost no research has been undertaken on this method.

AIM

The aim of the study was to investigate the effect of four different preventative regimes involving either frequent turning (2, 3 hourly) or the use of a pressure-reducing mattress in combination with less frequent turning (4, 6 hourly).

SUBJECTS

838 geriatric nursing home patients participated in the study.

METHODS

During 28 days, four different turning schemes were used: turning every 2 h on a standard institutional (SI) mattress (n = 65), turning every 3 h on a SI mattress (n = 65), turning every 4 h on a viscoelastic foam (VE) mattress (n = 67), and turning every 6h on a VE mattress (n = 65). The remaining patients (n = 576) received standard preventive care.

MAIN RESULTS

The incidence of non-blanchable erythema (34.8-38.1%) was not different between the groups. The incidence of grade II and higher pressure ulcers in the 4h interval group was 3.0%, compared with incidence figures in the other groups varying between 14.3% and 24.1%.

CONCLUSIONS

Turning every 4 h on a VE mattress resulted in a significant reduction in the number of pressure ulcer lesions and makes turning a feasible preventive method in terms of effort and cost.

The pressure sore: pathophysiology and principles of management

The pressure sore is a common clinical problem, although its pathophysiology and management are poorly appreciated by many physicians. The impact of these lesions in terms of patient morbidity and rehabilitation, and health care expenditures is great. Shearing forces, friction and moisture, as well as pressure, contribute to the development of these sores. This paper reviews the clinical settings, causative factors, complications, and principles of prevention and management of the pressure sore. Early surgical consultation is important, because of the deceptive nature and multiple sequelae of these wounds.

Predictive validity of the Braden Scale for pressure sore risk in a nursing home population

The predictive validity of the Braden Scale and the timing of assessment for optimal prediction of pressure sore development (PS) were studied in a nursing home population. Subjects (N = 102) over age 19, free of PS and admitted within the previous 72 hr, were randomly selected from consecutive admissions to a skilled nursing facility. Subjects were assessed for risk and skin condition every 48 to 72 hr for 4 weeks. Twenty-eight subjects (27.5%) developed a PS. A cut score of 18 used at the observation prior to the first recorded PS maximized prediction, producing a sensitivity of 79%, a specificity of 74%, a 54% predictive value of a positive test, 90% predictive value of a negative test, and 75% correct classification rate.

Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions

OBJECTIVE

To determine the incidence of pressure ulcers in varied populations, and whether demographic characteristics (age, gender, race) and primary diagnosis are factors in pressure ulcer development when the level of risk for developing ulcers is considered. To determine if there is a difference in the type of preventive services prescribed for persons who do or do not develop pressure ulcers when risk is controlled and whether differences can be related to demographic characteristics.

DESIGN

Cohort study.

SETTING

Two skilled nursing homes, two university operated tertiary care hospitals, and two Veteran's Administration Medical Centers (VAMCs) in Omaha, NE, Durham, NC, and Chicago, IL.

PATIENTS

A total of 843 randomly selected patients more than 19 years of age who did not have pressure ulcers on admission to their place of care. Subjects were 63% male, 79% white, and had a mean age of 63 (+/- 16) years.

MEASURES

A head-to-toe skin assessment for pressure ulcers recording site and stage of ulcers, scores for the Braden Scale for Predicting Pressure Sore Risk, demographic characteristics (age, sex, race), and primary diagnosis and preventive interventions (turning or repositioning orders and pressure reduction surface) were documented on the patient record. Observations were made every 48 to 72 hours for a minimum of 1 to a maximum of 4 weeks.

MAIN OUTCOME MEASURES

Presence/absence and stage of pressure ulcers.

MAIN RESULTS

One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care, VAMCs, and nursing homes, respectively. Logistic regression demonstrated that lower Braden Scale scores, older age and white race predicted pressure ulcers; gender was not predictive. Primary diagnoses were not significant predictors of pressure ulcer risk when the Braden Scale score was entered into the regression. Prescription of turning was predicted by Braden Scale scores and by white race, whereas prescription of pressure reduction was predicted by Braden Scale scores, white race, and female sex.

CONCLUSIONS

Risk assessment, rather than diagnoses or demographic characteristics, is recommended as the basis for prescriptive decisions. Risk assessment should cue health care providers to make more judicious use of turning and support surfaces to prevent pressure ulcers. Persons who are at risk for pressure ulcers should have turning and pressure reduction surfaces consistently prescribed and implemented. The costs and goals of preventive prescription for those not at risk for pressure ulcers should be considered.

Obesity: Impediment to Postsurgical Wound Healing

PURPOSE

To provide physicians and nurses with an overview of the impact of obesity on postoperative wound healing and how preplanning protocols can minimize skin and wound care problems in this patient population.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in reducing skin and wound care problems in their patients who are obese.

OBJECTIVES

After reading the article and taking the test, the participant will be able to: 1. Identify obesity-related changes in body systems and how these impede wound healing. 2. Identify complications of postoperative wound healing in obese patients and the assessments and intervention strategies that can reduce these complications. 3. Identify skin and wound care considerations for obese patients and the role of preplanning protocols in avoiding problems.

Nurses' attitudes, behaviours and perceived barriers towards pressure ulcer prevention

BACKGROUND

Pressure ulcers are not a plague of modern man; they have been known to exist since ancient Egyptian times. However, despite the increasing expenditure on pressure ulcer prevention, pressure ulcers remain a major health care problem. Although nurses do not have the sole responsibility for pressure ulcer prevention, nurses have a unique opportunity to have a significant impact on this problem.

AIMS AND OBJECTIVES

The specific aims of the study were to identify: * Staff nurses' attitudes towards pressure ulcer prevention. * The behaviour of staff nurses' in relation to pressure ulcer prevention. * Staff nurses' perceived barriers towards pressure ulcer prevention.

DESIGN

A cross-sectional survey method was used.

METHODS

A randomly selected sample of staff nurses (n = 300) working in an acute care setting in an urban location was invited to participate. Data were collected using a prepiloted questionnaire. Data analysis was carried out using SPSS version 10 and SPSS Text Smart version 1.1.

RESULTS

The nurses surveyed demonstrated a positive attitude towards pressure ulcer prevention. However, prevention practices were demonstrated to be haphazard and erratic and were negatively affected by lack of time and staff. These barriers prevented the nurses' positive attitude from being reflected into effective clinical practice. Education, although poorly accessed, or made available, was rarely cited as impeding practice in this area.

CONCLUSION

This study suggests that positive attitudes are not enough to ensure that practice change takes place, reinforcing the complex nature of behavioural change. Implementation strategies should introduce ways in which key staff can be empowered to overcome barriers to change.

RELEVANCE TO CLINICAL PRACTICE

This study provides a unique exploration of Irish nurses' attitudes, behaviours and perceived barriers towards pressure ulcer prevention, thereby contributing to the body of knowledge on this subject. As tissue viability is a new and emerging speciality, this information will contribute to evidence based practice in this area of patient care and will form the basis for the development of an educational strategy for pressure ulcer prevention and management.

A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex(®) Border Sacrum and Mepilex(®) Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi-layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.

A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation

The purpose of this study was to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. The multi-center trial involved 19 wards stratified according to specialty and recruitment for critically ill older patients; 9 wards were randomly selected for nutritional intervention (nutritional intervention group), consisting of the daily distribution of two oral supplements, with each supplement containg 200 kcal, for 15 d. Pressure ulcer incidence was prospectively recorded for grades I (erythema), II (superficial broken skin), and III (subcutaneous lesion) for 15 d. Nutritional intake was monitored by using estimates in units of quarters validated by comparison with weight measurement. There were 672 subjects older than 65 y, and 295 were in the nutritional intervention group versus 377 in the control group. The patients were similar for age, sex ratio, and C-reactive protein. In comparison with the control group, the nutritional intervention group included more patients with stroke, heart failure, and dyspnea and fewer with antecedent falls, delirium, lower limb fractures, and digestive disease. The nutritional intervention group had a lower risk of pressure ulcers according to the Norton score but was less dependent (Kuntzman score) and had a lower serum albumin level. During the trial, energy and protein intakes were higher in the nutritional intervention group (day 2: 1081 +/- 595 kcal versus 957 +/- 530 kcal, P = 0.006; 45.9 +/- 27.8 g protein versus 38.3 +/- 23.8 g protein in the control group, P < 0.001). At 15 d, the cumulative incidence of pressure ulcers was 40.6% in the nutritional intervention group versus 47.2% in the control group. The proportion of grade I cases relative to the total number of cases was 90%. Multivariate analysis, taking into account all diagnoses, potential risk factors, and the intra-ward correlation, indicated that the independent risk factors of developing a pressure ulcer during this period were: serum albumin level at baseline, for 1 g/L decrease: 1.05 (95% confidence interval: 1.02 to 1.07, P < 0.001); Kuntzmann score at baseline, for 1-point increase: 1.22 (0.32 to 4.58, P = 0.003); lower limb fracture: 2.68 (1.75 to 4.11, P < 0.001); Norton score < 10 versus > 14: 1.28 (1.01 to 1.62, P = 0.04); and belonging to the control group: 1.57 (1.03 to 2.38, P = 0.04). In conclusion, it was possible to increase the dietary intake of critically ill elderly subjects by systematic use of oral supplements. This intervention was associated with a decreased risk of pressure ulcer incidence.

How elderly patients with femoral fracture develop pressure sores in hospital

The routine hospital management of 100 consecutive elderly patients was studied to determine the reason for the high incidence of pressure sores among patients admitted to hospital for femoral fractures. Of these patients, 66 developed sores, 83% occurring by the fifth day in hospital. This was due to the long periods that patients were immobilised on high pressure surfaces in the casualty department, wards, and theatres before repair of the fracture and restoration of their weight bearing function. Sores are not simply a ward or nursing problem, but an unintended consequence of hospital treatment. To reduce the incidence of sores elderly patients should be treated on low pressure patient support systems from the point of entry to hospital until mobility is restored.

Predicting Pressure Injury in Critical Care Patients: A Machine-Learning Model

BACKGROUND

Hospital-acquired pressure injuries are a serious problem among critical care patients. Some can be prevented by using measures such as specialty beds, which are not feasible for every patient because of costs. However, decisions about which patient would benefit most from a specialty bed are difficult because results of existing tools to determine risk for pressure injury indicate that most critical care patients are at high risk.

OBJECTIVE

To develop a model for predicting development of pressure injuries among surgical critical care patients.

METHODS

Data from electronic health records were divided into training (67%) and testing (33%) data sets, and a model was developed by using a random forest algorithm via the R package "randomforest."

RESULTS

Among a sample of 6376 patients, hospital-acquired pressure injuries of stage 1 or greater (outcome variable 1) developed in 516 patients (8.1%) and injuries of stage 2 or greater (outcome variable 2) developed in 257 (4.0%). Random forest models were developed to predict stage 1 and greater and stage 2 and greater injuries by using the testing set to evaluate classifier performance. The area under the receiver operating characteristic curve for both models was 0.79.

CONCLUSION

This machine-learning approach differs from other available models because it does not require clinicians to input information into a tool (eg, the Braden Scale). Rather, it uses information readily available in electronic health records. Next steps include testing in an independent sample and then calibration to optimize specificity.

Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify risk and protective factors associated with a history of recurrent pressure ulcers among participants with spinal cord injury (SCI).

DESIGN

A mail survey was used to identify factors associated with the presence or absence of recurrent pressure ulcers.

SETTING

A large specialty hospital in the southeastern United States.

PARTICIPANTS

All participants had traumatic SCI, were nonambulatory, 18 years or older, and had been injured at least 5 years. A total of 826 subjects participated, 633 of whom reported a pressure ulcer history that could be classified as to whether they did or did not have a history of recurrent pressure ulcers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

History of pressure ulcers was measured by a single item that required participants to classify their history into 1 of 5 options, ranging from never having any pressure ulcers to having almost continuous pressure ulcers, often requiring hospitalization. Those who either never had a pressure ulcer or had them mostly for a short period after SCI onset were classified as nonrecurrent, whereas those who reported at least 1 per year were classified as recurrent.

RESULTS

Seventy percent of the participants failed to report recurrent pressure ulcers (never had any or had them only immediately after SCI onset), whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year. Logistic regression analyses suggested several general behaviors were protective for recurrent pressure ulcers, including lifestyle, exercise, and diet. Yet none of the behaviors generally recommended during inpatient rehabilitation specifically to prevent pressure ulcers (eg, skin checks weight shifts) were associated with pressure ulcer history. Only 2 risk behaviors were identified (number of cigarettes smoked, use of medication for sleep), although several proxy variables were related to pressure ulcer history.

CONCLUSIONS

Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A healthy lifestyle appears to be strongly associated with avoiding pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated. Problem solving and coping strategies should be targets for further research.