Analysis of pressure ulcer wound fluid using two‐dimensional electrophoresis

The incidence rate of pressure ulcers in the USA ranges from 0·4% to 38% in acute care settings and from 2·2% to 23·9% in long‐term care settings, and their treatment costs are in the billions of dollars yearly. The proteome of wound fluid may contain early indicators or biomarkers associated with healing in pressure ulcers that would enable treatment regimes to be optimised for each individual. Wound fluid was collected from the interior and periphery of 19 chronic pressure ulcers at 15 time points during 42 days for an analysis of protein expression. Proteins were fractionated using two‐dimensional polyacrylamide gel electrophoresis. A comparison of the spot distributions indicates a biochemical difference between the interior and the periphery of wounds. Pressure ulcers that healed show a greater number of spots for interior and peripheral locations combined over time when compared with wounds that did not heal. Using this technique, protein S100A9 was identified as a potential biomarker of wound healing. The identification of differences within the proteome of healing versus non healing pressure ulcers could have great significance in the use of current treatments, as well as the development of new therapeutic interventions.     

A national study of pressure ulcer prevalence and incidence in acute care hospitals.

OBJECTIVE: This study sought to establish national benchmarks for pressure ulcer prevalence and incidence among acute care health organizations served by Novation LLC. SETTING AND SUBJECTS: One hundred sixteen acute care facilities from 34 states participated; the sample consisted of 17,560 patients in hospital-based medical-surgical or intensive care units. INSTRUMENTS: Standardized education kits were provided to each participating site. The kits included an educational video about pressure ulcer staging, a post-test and answer key, and assessment form for patient data collection. METHODS: Pressure ulcer prevalence was measured during a predetermined 24-hour period at each facility. Incidence was measured over the average length of stay determined for each participating facility. Subjects were assessed by teams consisting of a registered nurse and one other health care professional (e.g. licensed practical nurse, physical therapist). Demographic, wound, and other data were collected for these patients. Data collection forms were audited and submitted to a central site for database entry, analysis, and generation of reports. RESULTS: The average length of stay for the participating facilities was 5 days. Pressure ulcers developed in 7% of the subjects (n = 383); 90% were stage I or II pressure ulcers, and 73% occurred in patients older than 65 years. The most sites based on both prevalence and incidence measurements were the sacrum and coccyx at 26% and 31%, respectively. CONCLUSIONS: Prevalence and incidence studies must be routinely conducted to clearly identify the extent of the pressure ulcer problem to provide guidance for efficient and effective corrective action.     

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9‐year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual‐care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital‐acquired pressure ulcers decreased following implementation of an evidence‐based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual‐care nurses under‐estimated patients' risk of pressure ulcer development and under‐utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital‐acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.     

Point prevalence of wounds in a sample of acute hospitals in Canada

To provide new information on wound prevalence and the potential resource impact of non healing wounds in the acute sector by summarising results from wound audits carried out at 13 acute hospitals in Canada in 2006 and 2007. Audits were carried out in each hospital by the same independent team of advanced practice nurses using standard data‐collection forms. The results reported here were derived from the summary reports for each hospital. A total of 3099 patients were surveyed (median 259 patients per hospital). In the sample hospitals, the mean prevalence of patients with wounds was 41·2%. Most wounds were pressure ulcers (56·2%) or surgical wounds (31·1%). The mean prevalence of pressure ulcers was 22·9%. A majority of pressure ulcers (79·3%) were hospital‐acquired, and 26·5% were severe (Stage III or IV). The rate of surgical wound infection was 6·3%. Forty‐five percent of patients had dressings changed at least daily and the mean dressing time was 10·5 minutes. Wounds are a common and potentially expensive occurrence in acute hospitals. Any wound has the potential to develop complications which compromise patient safety and increase hospital costs. Ensuring consistent, best‐practice wound management programmes should be a key priority for hospital managers.     

Surgery for pressure ulcers in spinal cord‐injured patients following a structured treatment programme: a 10‐year follow‐up

With the aim to improve the outcomes for spinal cord‐injured patients undergoing surgery for pressure ulcers, a structured treatment programme regulating pre‐ and postoperative care and rehabilitation was introduced in 2002 in Stockholm. Fifty‐one consecutive patients operated on between 2002 and 2007 were included in a 10‐year follow‐up to evaluate the programme regarding initial healing results and long‐term ulcer and health status. At one month postoperatively, 49 out of 51 (96%) patients were completely healed. Five patients (5/44, 11%) developed recurrent or new ulcers within 3 years of surgery. Two patients were re‐operated on (2/44, 5%). Between 3 and 10 years after surgery, 9 patients (9/33, 27%) had a history of recurrent ulcers, and 6 (6/33, 18%) had a history of new ulcers, a total of 15 patients (15/33, 45%). Of these, three needed re‐operation (3/33, 9 %). The health status values using a visual analogue rating scale were 70 (median) at 3 and 10 years compared with 30 (median) preoperatively. The good initial healing, the low ulcer recurrence rate and the raise in health status indicate the value of a structured treatment programme, especially for the first few postoperative years.     

Pressure ulcers in four Indonesian hospitals: prevalence,patient characteristics,ulcer characteristics,prevention and treatment

The objective of this article was to study characteristics of pressure ulcer patients and their ulcers, pressure ulcer preventive and treatment measures in four Indonesian general hospitals. A multicentre cross‐sectional design was applied to assess pressure ulcers and pressure ulcer care in adult patients in medical, surgical, specialised and intensive care units. Ninety‐one of the 1132 patients had a total of 142 ulcers. Half (44·0%) already had pressure ulcers before admission. The overall prevalence of category I–IV pressure ulcers was 8·0% (95% CI 6·4–9·6), and the overall nosocomial pressure ulcer prevalence was 4·5% (95% CI 3·3–5·7). Most pressure ulcer patients had friction and shear problems, were bedfast, had diabetes and had more bedridden days. Most ulcers (42·3%) were category III and IV. One third of the patients had both pressure ulcers and moisture lesions (36·3%) and suffered from pain (45·1%). The most frequently used prevention measures were repositioning (61·5%), skin moisturising (47·3%), patient education (36·3%) and massage (35·2%). Most pressure ulcer dressings involved saline‐impregnated or antimicrobial gauzes. This study shows the complexities of pressure ulcers in Indonesian general hospitals and reveals that the quality of pressure ulcer care (prevention and treatment) could be improved by implementing the recent evidence‐based international guideline.     

The prevalence of pressure ulcers in community‐dwelling older adults: A study in an Indonesian city

The objectives of this study were to investigate the prevalence and the characteristics of pressure ulcers (PU) in community‐dwelling older adults in Indonesia, including specific characteristics of the PU patients and their use of formal and informal care. A cross‐sectional design was used for the study, with 325 participants aged 60 years or older, randomly chosen from the general community. The overall PU prevalence and the PU prevalence excluding category 1 were 10.8% (95% confidence interval [CI], 5.8‐15.8) and 5.2% (95% CI 0.2‐10.2), respectively. Category 1 PUs were mostly (34.3%) located on knees and toes, while category 2 and higher PUs were mostly (70.4%) located on the shoulder, sacrum, and hip. The main factors that contributed strongly to PUs among older adults in the community were the degree of physical activity, problems with sensory perception, and having a history of stroke. None of the participants with a PU received wound care or information about PUs from formal caregivers and only 11.4% received wound care from family caregivers. This study shows that pressure ulcers in community‐dwelling older adults in Indonesia are a relevant and largely unaddressed problem. Developing an intervention program to manage the PU problem in the community is recommended.     

Concordance of Shape Risk Scale,a new pressure ulcer risk tool,with Braden Scale

The occurrence of pressure ulcers was examined in a cross‐sectional study in 23 health care facilities and in home care involving 548 patients. The screening of pressure ulcer risk was assessed simultaneously using the Braden Scale and the new Shape Risk Scale (SRS), and the results were compared. The overall prevalence of pressure ulcers in the study population was 15·5% (85/548). The Braden Scale was performed as described in the literature. The direct concordance of the Braden and SRS scales was 46%. In more than 90% of cases, the SRS classified patients as well as or better than the Braden Scale. The SRS allocates patients significantly different from the Braden Scale into the risk categories, especially the difference is significant between the low and medium‐risk categories. The greatest advantage of SRS to Braden Scale is that it correctly identifies patients with low risk of pressure ulcers. It is interesting that the two risk scores, taking into consideration the basically different pathophysiological factors, can still give rather similar results. The users considered that both scales are easy to use.     

The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital.

OBJECTIVE: To describe the pressure ulcer prevalence, stage and body location, and demographic characteristics of patients with pressure ulcers at a tertiary care adult hospital and a tertiary care pediatric hospital. DESIGN: Prevalence survey. SETTING AND SUBJECTS: A total of 513 inpatients, including 416 adults admitted to a tertiary care hospital and 97 children admitted to a tertiary care pediatric hospital. Only inpatients with mental health-related diagnoses were excluded. INSTRUMENTS: The Kinetics Concepts International's Prevalence and Incidence Study Collection Form was used to assess variables, including demographic information; presence, location, and stage of pressure ulcers; and presence of special support surfaces. METHODS: All patients had head-to-toe skin assessments performed during an 8-hour period by teams of 3 multidisciplinary staff members. Kinetics Concepts International's Prevalence and Incidence Program software and Microsoft Excel were used for data entry and analysis. RESULTS: Combined pressure ulcer prevalence was 26.3%, with 29.2% in adult patients and 13.1% in pediatric patients. The most common body locations for pressure ulcers were the sacrum (22.1%), heels (14.8%), ears (12.9%), elbows (10.6%), and the buttocks (6.8%). Forty-eight percent of the ulcers were stage I, 36% Stage II, 6% Stage III-IV, and 10% unable to stage. CONCLUSIONS: Overall combined pressure ulcer prevalence and common body locations were consistent with findings from comparable hospitals. Patients at the extreme ends of the age spectrum had an increased risk of pressure ulcers. Stage I and II ulcers occurred most frequently. Potential prevention and early management strategies may be effective in decreasing the prevalence of these ulcers.     

Improving the quality of pressure ulcer management in a skilled nursing facility

Pressure ulcers (PUs) are a serious health care problem for nursing home residents and a key quality metric for regulators. Three initiatives were introduced at a 128‐bed facility to improve PU prevention. First, a Quality Assurance and Performance Improvement project and a Root Cause Analysis were conducted to improve the facility's wound care programme. Second, a digital wound care management solution was adopted to track wound management. Third, the role of skin integrity coordinator was created as a central point of accountability for wound care‐related activities and related performance metrics. Improvements in PU prevention were tracked using Centers of Medicare and Medicaid data, specifically (a) the percentage of long‐stay high‐risk residents with PUs and (b) the percentage of short‐stay residents with PUs that are new or have worsened. PU prevalence for long‐stay high‐risk residents was 12.99% (Q4 2016), and upon implementation of these initiatives, the facility saw continued reductions in PU prevalence to 2.9% (Q4 2017), while PUs for short‐stay residents were maintained at zero throughout this period. This study highlights the power of effective management combined with real‐time data analytics, as enabled by digital wound care management, to make significant improvements in health care delivery.     

A prospective window into medical device‐related pressure ulcers in intensive care

The aim of this study was to determine the prevalence, severity, location, aetiology, treatment and healing of medical device‐related pressure ulcers (PUs) in intensive care patients for up to 7 days. A prospective repeated measures study design was used. Patients in six intensive care units of two major medical centres, one each in Australia and the USA, were screened 1 day per month for 6 months. Those with device‐related ulcers were followed daily for up to 7 days. The outcome measures were device‐related ulcer prevalence, pain, infection, treatment and healing. Fifteen of 483 patients had device‐related ulcers and 9 of 15 with 11 ulcers were followed beyond screening. Their mean age was 60·5 years, and most were men, overweight and at increased risk of PU. Endotracheal (ET) and nasogastric (NG) tubes were the cause of most device‐related ulcers. Repositioning was the most frequent treatment. Four of 11 ulcers healed within the 7‐day observation period. In conclusion, device‐related ulcer prevalence was 3·1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device‐related ulcers, especially in patients with NG and ET tubes.     

Hospital-acquired pressure ulcers in two Swedish County Councils: cross-sectional data as the foundation for future quality improvement

The objectives of the study were to examine the prevalence of pressure ulcers and hospital-acquired pressure ulcers (HAPU) and identify modifiable factors in patients who develop HAPU as the basis for subsequent quality assurance studies and improvement in hospital care. The study was conducted in five hospitals in two Swedish County Councils. A 1-day prevalence study (n = 1192) using the standards of the European Pressure Ulcer Advisory Panel and Collaborative Alliance for Nursing Outcomes was conducted. The prevalence of ulcers was 14·9% and 11·6% were HAPU. Older age, more days of hospitalisation, less activity, problems with shear and friction and reduced sensory perception contributed significantly to HAPU. Pressure ulcer prevention strategies used more often in those with HAPU were risk assessment at admission, provision of a pressure relief mattress, having a turning schedule and using a heel or chair cushion. The prevalence of pressure ulcers continues to be a significant issue in acute care and the prevalence of HAPU is high. There is significant room for quality improvement in pressure ulcer prevention in Swedish hospitals. Future research needs to address both HAPU and community-acquired pressure ulcers and focus on preventive strategies, including when they are initiated and which are effective in mitigating the high HAPU rate.     

Risk factors for pressure ulcers among elderly hip fracture patients

The purpose of this study was to estimate the incidence of hospital-acquired pressure ulcers among elderly patients hospitalized for hip fracture surgery and to identify extrinsic factors that are associated with increased risk. We conducted a secondary analysis of data abstracted from medical records at 20 hospitals in Pennsylvania, Texas, New Jersey, and Virginia. Participants were patients aged 60 years and older admitted with hip fracture to the study hospitals between 1983 and 1993. The incidence of hospital-acquired pressure ulcers was 8.8% (95% confidence interval 8.2%-9.4%). After adjusting for confounding variables, longer wait before surgery, intensive care unit stay, longer surgical procedure, and general anesthesia were significantly associated with higher pressure ulcer risk. Extrinsic factors may be important markers for high pressure ulcer risk in hospitalized hip fracture patients. Although it is not possible to eliminate factors such as requiring an intensive care unit stay or having a long surgical procedure, it may be possible to develop interventions that minimize pressure ulcer risk in patients who experience these factors.     

Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set

The survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcer prevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between 2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conducted between 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48·6% within orthopaedic units with 615 located in community hospitals). Of these patients, 81 (13·9%) and 162 (26·7%) had pressure ulcers in orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, the most severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be either category I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categories III and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption of the EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence in different health care organisations and specialities. The adoption of a consistent data collection capture methodology is a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.     

Estimating the costs associated with the management of patients with chronic wounds using linked routine data

Chronic wounds are known to represent a significant burden to patients and National Health Service (NHS) alike. However, previous attempts to estimate the costs associated with the management of chronic wounds have been based on literature studies or broad estimates derived from incidence rates and extrapolations from relatively small‐scale studies. The aim of this study is therefore to determine the extent of resource utilisation by patients classed as having chronic wounds within Wales using linked routine data – available through the Secure Anonymised Information Linkage (SAIL) database – to estimate the costs associated with the management of these patients by the NHS in Wales. The SAIL database brings together, and anonymously links, a wide range of person‐based data from general practitioner (GP) practices within Wales, which includes primary and secondary care consultations to create an encrypted anonymised linking field for each individual. This linkage allows the patient pathway to be tracked through the NHS system both retrospectively and prospectively from a specific reference date. The estimated costs were derived by extrapolating to an all‐Wales level from the results gleaned from the SAIL database using the respective READ codes to capture relevant patients with chronic wounds. The number of patients identified as having chronic wounds within the SAIL database was 78 090, which equates to 190 463 across Wales as a whole and a prevalence of 6% of the Welsh population. The total cost of managing patients with chronic wounds in Wales amounted to £328·8 million – an average cost of £1727 per patient and 5·5% of total expenditure on the health service in Wales. A relatively few READ codes represented a significant proportion of expenditure, with diabetic foot ulcers, leg ulcers, foot ulcers, varicose eczema, bed sores and postoperative wound care constituting 93% of total expenditure. When a more conservative perspective was used in relation to classification of chronic wounds, the total cost amounted to £303 million. However, these are likely to be underestimates because of the lack of information for patients with treatments lasting over 6 months and not including patients who might have entered the health care system of wound management elsewhere – such as patients contracting pressure ulcers in hospitals and having surgical wound infections.     

Evaluation of a multifactorial approach to reduce the prevalence of pressure injuries in regional Australian acute inpatient care settings

The aim of the study was to compare the changes in the prevalence of pressure injuries from 2008 to 2014 in relation to staff behaviour in acute/subacute inpatient care settings. In 2008, the large regional health district Hunter New England Local Health District implemented an initiative called the Crystal Model which resulted in changes in their policy and an e‐learning education program for all nursing staff. A retrospective cross sectional study compared data from the 2008, 2010 and 2014 point prevalence surveys of PI in acute services. These were collected as part of an annual pressure injury prevention and management quality audit for adult inpatients. The total number of participants included 1407 participants in 2008, 1331 participants in 2010 and 1199 participants in 2014. From 2008 to 2014 there was a 15.7% decrease in percentage of patients with hospital‐acquired pressure injuries and the percentages of each stage of pressure of injury 1–4 decreased. From 2008 to 2014 the completion and documentation of risk assessment, the documentation of repositioning and the implementation of pressure‐relieving equipment increased. A multifactorial model can reduce the prevalence of pressure injuries in acute inpatient settings. The theories of knowledge translation and the modified Theory of Planned Behaviour can be utilised to analyse changes in health professionals habituated pressure injury prevention practice     

Prevalence of pressure ulcers on hospital admission among nursing home residents transferred to the hospital

The purpose of this study was to compare the prevalence of pressure ulcers among newly hospitalized nursing home residents and among newly hospitalized patients from nonnursing home settings. Study participants were at least 65 years old and admitted through the emergency department to one of two study hospitals. Research nurses ascertained the presence of pressure ulcers (stage 1–4) by visual skin assessment on the third day following admission to the hospital unit. Other data were collected by clinical examination, interview, and medical record review. The prevalence of preexisting pressure ulcers at the time of admission was 26.2% among those admitted from a nursing home and 4.8% among those admitted from another living situation (odds ratio 5.5, 95% confidence interval 4.3–7.1). After adjustment for confounders, the association between admission from a nursing home and pressure ulcer prevalence on admission was reduced (odds ratio 1.51, 95% confidence interval 1.03–2.23). These results indicate that admission from a nursing home is a potent marker for pressure ulcer risk and that the excess risk is largely mediated by the higher prevalence of pressure ulcer risk factors among patients admitted from a nursing home. The results highlight the importance of continuity of care across transitions between care settings.