Preventing pressure ulcers: the goal is zero

BACKGROUND: One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is "Prevent Pressure Ulcers ... by reliably using science-based guidelines for their prevention." Pressure ulcers cause considerable harm to patients, hindering functional recovery, frequently causing pain, and often serving as vehicles for the development of serious infections. Although the goal for health care facilities to reduce pressure ulcers is admirable, the goal for pressure ulcer incidence should be zero. THE CASE FOR PREVENTION: Pressure ulcer prevention entails two major steps: identifying patients at risk and reliably implementing prevention strategies for all patients identified as at risk. Prevention strategies include six key elements (elements 3-6 address patients at risk): (1) conduct a pressure ulcer admission assessment for all patients, (2) reassess risk for all patients daily, (3) inspect skin daily, (4) manage moisture, (5) optimize nutrition and hydration, and (6) minimize pressure. Facilities may wish to form a multidisciplinary team to develop a pressure ulcer prevention program. CONCLUSION: The development of pressure ulcers is a painful, expensive, and unnecessary harm event that is all too prevalent in American hospitals. The prevention of pressure ulcers is a key intervention that is not new, not expensive, and has the potential to save thousands of patients from unnecessary harm.     

Are all pressure ulcers avoidable?

A quality of care debate centers on whether pressure ulcers result from factors largely dependent on caregivers, or whether pressure ulcers result from factors associated with patient morbidity. A reduction in incidence, defined as the development of a new pressure ulcer, is the focus of prevention strategies. Yet epidemiological data demonstrates a stability in the incidence of pressure ulcers despite drastic improvements in understanding of pressure ulcers, increased regulatory oversight, and improvements in technologies available for prevention of pressure ulcers. The explanation for this stable incidence of pressure ulcers includes a failure of known effective preventive treatment to be applied or the failure of prevention strategies to be effective in spite of being applied. No intervention strategy has been reported that consistently and reproducibly reduces the incidence of pressure ulcers to zero. The published data on prevention of pressure ulcers do not support an assumption that all pressure ulcers are preventable. An effective prevention strategy demonstrated to eliminate pressure ulcers across healthcare settings is lacking.     

Scalability of an IT Intervention to Prevent Pressure Ulcers in Nursing Homes

BackgroundPressure ulcers pose an important quality-of-care challenge in nursing homes, with serious consequences for residents' health. We assessed the scalability of the On-Time Pressure Ulcer Prevention (On-Time) intervention strategy, developed by the Agency for Healthcare Research & Quality, in nursing homes nationwide.InterventionOn-Time uses electronic health record reports to identify changes in resident pressure ulcer risk and facilitate multidisciplinary input into clinical decision making.ObjectiveTo assess the scalability and impact of On-Time on pressure ulcer incidence in nursing homes.DesignWe used quasi-experimental methods, employing a difference-in-differences design, to compare the pre-post trends in pressure ulcer incidence in the treatment and comparison homes.Setting and participantsThe study population included long-stay residents at high risk for developing pressure ulcers in 47 nursing homes and matched comparison homes in 17 states.MeasuresStage 2 to 4 pressure ulcer incidence among long-stay residents who met the criteria for high risk, identified using an algorithm adapted from the Minimum Data Set 3.0 Percent of High-Risk Residents with Pressure Ulcers (Long Stay) measure.ResultsThe overall decline in pressure ulcer rates for treatment relative to matched comparison homes was statistically insignificant (P > .05). A subgroup of heterogeneous homes experienced a statistically significant decline of 3.24 percentage points (61.0% relative decrease) in pressure ulcer rates relative to matched comparison homes, but no uniting characteristic common across homes readily explained their success.Conclusions/ImplicationsScalability of future health information technology–based quality improvement interventions in nursing home settings requires nuanced implementation support, particularly around electronic health record report accessibility and accuracy.     

Hypotension Is a Risk Factor for New Pressure Ulcer Occurrence in Older Patients After Admission to an Acute Hospital

BackgroundPressure ulcer occurrence in older patients admitted to hospital has not been studied thoroughly; yet, pressure ulcers frequently develop among the frail older patients who are hospitalized. Identifying risk factors for pressure ulcer occurrence is of utmost importance in preventing its development in this group of patients. Hypoperfusion, as manifested by hypotension, is theoretically important in the development of pressure ulcer. However, studies on this aspect are scarce.ObjectiveTo examine whether a hypotensive episode (systolic blood pressure less than or equal to 90 mm Hg) is associated with pressure ulcer occurrence.MethodThis was a retrospective cohort study in a regional hospital. It recruited 259 patients aged 65 or older who were admitted to a convalescence ward and had a hospital stay for more than 5 days. Baseline clinical characteristics and the possible risk factors of pressure ulcer occurrence on admission and any episode of hypotension were recorded. The primary outcome measured was the incidence of pressure ulcer occurrence in the index admission.ResultsHypotension was strongly associated with incident pressure ulcer occurrence (odds ratio 6.71, P = .001).ConclusionsHypotension was an important risk factor for incident pressure ulcer occurrence during hospital stay. Every effort has to be taken to try to prevent hypotension. Precautions to prevent pressure ulcer development should be taken on patients who are hypotensive.     

Tabaco y publicidad. Revisión de los estudios publicados entre 2000 y 2008

ObjectiveTo evaluate the influence of tobacco advertising on consumer habits.DesignSystematic review.Data sourcesPubMed, Ovid, Scielo, Mediclatina, Elsevier-Doyma, Isooc (CSIC) (January 2000-September 2008)MethodsA total of 44 national and international articles, linking the consumption of tobacco with any promotional or advertising practice. Articles not focused on the impact of advertising and promotion of cigarettes and research on prevention, intervention, plans and laws were removed.ResultsAdvertising influences tobacco consumption. Publicity leads to starting smoking (5 articles) and maintaining the habit (3 articles). It uses the relationship between advertising and smoker's image and concept (5 articles) and different advertising strategies (22 articles).ConclusionsThe advertising developed by the tobacco industry uses different strategies of influence on the consumption of cigarettes in the population.     

Do Patients in Dutch Nursing Homes Have More Pressure Ulcers Than Patients in German Nursing Homes? A Prospective Multicenter Cohort Study

ObjectivesTo investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents.DesignA prospective multicenter cohort study.SettingTen nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg).ParticipantsA total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer.MeasurementsData were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants.ResultsA significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home.ConclusionThe pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls.     

Pressure ulcers and endothelial dysfunction: is there a link?

Pressure ulcers were first described in the medical literature in the mid-16th century. Today, in the 21st century, pressure ulcers continue to cause pain and suffering to patients and increase the cost of medical care. Researchers and clinicians have used significant time and money to develop prevention and treatment strategies for pressure ulcers. Accepted risk factors for pressure ulcer development include pressure, shear force, friction, moisture and malnutrition. Yet despite procedures to help minimize these risk factors, pressure ulcers are still problematic. Endothelial dysfunction, which is a well-documented cardiovascular risk factor, has been proposed as another risk factor for pressure ulcers. Yet little is known about how pressure ulcers and endothelial dysfunction are linked. In this article we explore the literature to build an argument that research into the role of endothelial function is a plausible line of translational investigation that would contribute greatly to the knowledge base that guides present-day practices in the prevention and treatment of pressure ulcers.     

Reduce the pain and high costs associated with pressure ulcers

For patients who suffer immobility or cognitive problems, institutionalization can bring on a whole new set of problems in the form of pressure ulcers. Pressure ulcers can be prevented using strict risk assessment measures, but many hospitals and skilled nursing facilities fail to use these strategies, resulting in extended lengths of stay. Find out how one provider collaborative attacked the problem, plus use their pressure ulcer prevention tool in your own facility.     

Occupational therapists’ perceptions of habits based on their professional experiences

Background: Habits are building blocks for occupation. If they are not explicitly approached, a vital aspect of occupation may be left out. Knowledge is lacking about how habits are understood and approached in occupational therapy practice.

Aim: To explore occupational therapists’ perceptions of habits based on their professional experiences.

Material and methods: A qualitative design with a focus group methodology was used. The qualitative data analysis was based on five focus group discussions, including 34 occupational therapists.

Results: An overarching theme, ‘the complexity of habits,’ representing the occupational therapists’ perception of habits, covers the content of three categories: ‘reflecting contradictoriness,’ including different forms of ambiguity that characterize habits, ‘reflecting identity and security’, that emphasize the meaning of habits for identity and structure in everyday life, and ‘reflecting context and society’, comprising perceptions of habits related to the life situation, time and social patterns and environment.

Conclusions: The occupational therapists’ perceptions gave a picture of habits as complex systems. Based on the findings, the therapeutic modes used when approaching clients’ habits should involve more explicit attention to habits and the inclusion of the client’s entire context.     

Malnutrition and pressure ulcer risk in adults in Australian health care facilities

ObjectiveTo determine the effect of nutritional status on the presence and severity of pressure ulcer.MethodsA multicenter, cross-sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of Queensland, Australia, public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and 6 residential aged care facilities conducted single-day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence and severity (highest stage and number of pressure ulcers) was determined by logistic regression in a model controlling for age, gender, medical specialty, and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach.ResultsSubjects with malnutrition had adjusted odds ratios of 2.6 (95% confidence interval 1.8–3.5, P < 0.001) of having a pressure ulcer in acute care facilities and 2.0 (95% confidence interval 1.5–2.7, P < 0.001) for residential aged care facilities. There was also increased odds ratio of having a pressure ulcer, and having a more severe pressure ulcer (higher stage pressure ulcer and/or a higher number) with increased severity of malnutrition.ConclusionMalnutrition was associated with at least twice the odds ratio of having a pressure ulcer of in public health care facilities in Queensland. Action must be taken to identify, prevent, and treat malnutrition, especially in patients at risk of pressure ulcer.     

NEWS

Background: Psychosocial factors such as depressive symptoms should be considered when assessing cardiovascular (CV) risk. Depressive symptoms are suggested to be associated with poor perception of one’s health, i.e. self-rated health (SRH). Thus, assessing SRH could be a practical tool in CV risk prediction. However, SRH may also emphasize physical, mental or social aspects.

Objectives: To assess the relationship of SRH and depressive symptoms, classic CV risk factors and perceived physical health among persons at risk for type 2 diabetes (T2D) and cardiovascular disease (CVD).

Methods: In this cross-sectional study in a primary care population, 2555 persons (mean age 58?±?7, 56% women) at risk for T2D or CVD were evaluated. Generalized linear statistical models were used to evaluate the association of depressive symptoms (Beck’s Depression Inventory score ≥10), CV risk factors, and perception of SRH and physical health (assessed by Short Form Health Survey).

Results: Poor or fair health was reported by 40% of the participants. They had more unhealthy lifestyle habits and CV risk factors than subjects rating their health as at least good. Among those with poor or fair SRH, the prevalence of depressive symptoms was 36% and associated with perception of physical health.

Conclusion: Poor SRH is associated with depressive symptoms and impaired perceived physical health. Assessing SRH might be useful for detecting possible depressive symptoms in patients in CV risk management and diabetes care.     

危重新生儿压疮高危因素分析及护理对策

目的探讨危重新生儿压疮发生的高危因素,并总结相应有效的预防护理对策。方法对人住NICU的危重新生儿压疮高危因素进行分析评估,采取相应的预防对策。结果发生压疮12例,压疮发生率0．76％。结论针对引发新生儿压疮的各类危险因素进行相应的预防护理,对于降低压疮的发生具有重要意义。     

Errors of alternative medicine: lessons for general practice

Abstract

Background: Due to the importance of family medicine and a relative shortage of doctors in this discipline, it is important to know how the decision to choose a career in this field is made.

Objective: Since this decision is closely linked to students’ attitudes towards family medicine, we were interested in identifying those attitudes that predict intended career choice in family medicine.

Methods: A cross-sectional study was performed among 316 final-year medical students of the Ljubljana Medical Faculty in Slovenia. The students filled out a 164-item questionnaire, developed based on the European definition of family medicine and the EURACT Educational Agenda, using a seven-point Likert scale containing attitudes towards family medicine. The students also recorded their interest in family medicine on a five-point Likert scale. Attitudes were selected using a feature selection procedure with artificial neural networks that best differentiated between students who are likely and students who are unlikely to become family physicians.

Results: Thirty-one out of 164 attitudes predict a career in family medicine, with a classification accuracy of at least 85%. Predictors of intended career choice in family medicine are related to three categories: understanding of the discipline, working in a coherent health care system and person-centredness. The most important predictor is an appreciation of a long-term doctor–patient relationship.

Conclusion: Students whose intended career choice is family medicine differ from other students in having more positive attitudes towards family physicians’ competences and towards characteristics of family medicine and primary care.     

Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy

BACKGROUND: Chronic wounds such as leg ulcers, diabetic foot ulcers and pressure sores are common in both acute and community healthcare settings. The prevention and treatment of these wounds involves many strategies: pressure-relieving beds, mattresses and cushions are universally used as measures for the prevention and treatment of pressure sores; compression therapy in a variety of forms is widely used for venous leg ulcer prevention and treatment; and a whole range of therapies involving laser, ultrasound and electricity is also applied to chronic wounds. This report covers the final three reviews from a series of seven. AIMS: To assess the clinical effectiveness and cost- effectiveness of: (1) pressure-relieving beds, mattresses and cushions for pressure sore prevention and treatment; (2) compression therapy for the prevention and treatment of leg ulcers; (3) low-level laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy for the treatment of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases, including MEDLINE, CINAHL, EMBASE and the Cochrane Controlled Trials Register (CENTRAL), were searched. Relevant journals, conference proceedings and bibliographies of retrieved papers were handsearched. An expert panel was also consulted. METHODS - STUDY SELECTION: Randomised controlled trials (RCTs) which evaluated these interventions were eligible for inclusion in this review if they used objective measures of outcome such as wound incidence or healing rates. RESULTS - BEDS, MATTRESSES AND CUSHIONS FOR PRESSURE SORE PREVENTION AND TREATMENT: A total of 45 RCTs were identified, of which 40 compared different mattresses, mattress overlays and beds. Only two trials evaluated cushions, one evaluated the use of sheepskins, and two looked at turning beds/kinetic therapy. RESULTS - COMPRESSION FOR LEG ULCERS: A total of 24 trials reporting 26 comparisons were included (two of prevention and 24 of treatment strategies). RESULTS - LOW-LEVEL LASER THERAPY, THERAPEUTIC ULTRASOUND, ELECTROTHERAPY AND ELECTROMAGNETIC THERAPY: Four RCTs of laser (for venous leg ulcers), 10 of therapeutic ultrasound (for pressure sores and venous leg ulcers), 12 of electrotherapy (for ischaemic and diabetic ulcers, and chronic wounds generally) and five of electromagnetic therapy (for venous leg ulcers and pressure sores) were included. Studies were generally small, and of poor methodological quality. CONCLUSIONS (1) Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure sores in people at risk, as can pressure-relieving overlays on the operating table. One study suggests that air-fluidised therapy may increase pressure sore healing rates. (2) Compression is more effective in healing venous leg ulcers than is no compression, and multi-layered high compression is more effective than single-layer compression. High-compression hosiery was more effective than moderate compression in preventing ulcer recurrence. (3) There is generally insufficient reliable evidence to draw conclusions about the contribution of laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy to chronic wound healing.     

Modeling Hospital-Acquired Pressure Ulcer Prevalence on Medical-Surgical Units: Nurse Workload,Expertise, and Clinical Processes of Care

ObjectiveThis study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.ConclusionsUnit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.AimThis study modeled the predictive power of measures representing patient characteristics, nurse workload, nurse expertise, and HAPU preventive clinical processes of care on HAPU prevalence.     

Women Veterans’ Perspectives on Suicide Prevention in Reproductive Health Care Settings: An Acceptable,Desired, Unmet Opportunity

BackgroundWomen veterans of reproductive age experience a suicide rate more than double their civilian peers. Developing effective suicide prevention strategies for women veterans requires identifying settings frequented by women veterans where acceptable prevention initiatives can be implemented. Reproductive health care (RHC) settings may provide such an opportunity.MethodsWe conducted semi-structured interviews with 21 cisgender women veterans of reproductive age using RHC services provided or paid for by the Department of Veterans Affairs (VA) to understand their beliefs, attitudes, and preferences regarding suicide risk assessment and prevention within these settings. Interview analysis was inductive and used a thematic analysis framework.ResultsFour major themes emerged from the interviews: 1) positive patient-provider relationships in RHC settings are important; 2) some women veterans prefer women providers for RHC and suicide risk screening; 3) women veterans’ experiences with VA suicide risk screening and assessment vary; and 4) suicide risk screening and prevention in RHC settings is a desired and acceptable, yet unmet opportunity.ConclusionsFindings from this novel study suggest that VA RHC settings may present a viable milieu for implementing upstream, gender-sensitive, veteran-centric suicide prevention strategies. Future research is needed with VA RHC providers to determine their needs for successfully implementing such strategies.     

Sources of misunderstanding numbers needed to treat

Background: Selective prevention of cardiometabolic diseases (CMD)—that is, preventive measures specifically targeting the high-risk population—may represent the most effective approach for mitigating rising CMD rates.

Objectives: To develop a universal concept of selective CMD prevention that can guide implementation within European primary care.

Methods: Initially, 32 statements covering different aspects of selective CMD prevention programmes were identified based on a synthesis of evidence from two systematic literature reviews and surveys conducted within the SPIMEU project. The Rand/UCLA appropriateness method (RAM) was used to find consensus on these statements among an international panel consisting of 14 experts. Before the consensus meeting, statements were rated by the experts in a first round. In the next step, during a face-to-face meeting, experts were provided with the results of the first rating and were then invited to discuss and rescore the statements in a second round.

Results: In the outcome of the RAM procedure, 28 of 31 statements were considered appropriate and three were rated uncertain. The panel deleted one statement. Selective CMD prevention was considered an effective approach for preventing CMD and a proactive approach was regarded as more effective compared to case-finding alone. The most efficient method to implement selective CMD prevention systematically in primary care relies on a stepwise approach: initial risk assessment followed by interventions if indicated.

Conclusion: The final set of statements represents the key characteristics of selective CMD prevention and can serve as a guide for implementing selective prevention actions in European primary care.     

Implementation of a new policy results in a decrease of pressure ulcer frequency.

OBJECTIVE: To determine the effects of a new policy on the efficiency of pressure ulcer care. DESIGN: Series of 1-day pressure ulcer surveys before and after the implementation. SETTING: A 900-bed University Medical Centre in The Netherlands. PARTICIPANTS: On the days of the surveys, 657 patients were included before the implementation, 735 patients at 4 months after the implementation, and 755 patients at 11 months after the implementation. INTERVENTION: Implementation of a hospital guideline for pressure ulcer care combined with the introduction of viscoelastic foam mattresses on the efficiency of the prevention and treatment of pressure ulcers. MAIN OUTCOME MEASURES: Comparisons before versus after the implementation were made regarding the care behaviour of nurses and the frequency of patients with pressure ulcer. RESULTS: Inadequate prevention decreased from 19 to 4% after 4 months and to 6% after 11 months (P < 0.001), and inadequate treatment decreased from 60 to 31% (P = 0.005). Excluding the use of mattresses as a positive indicator for care behaviour, we found no significant increase in adequate care to prevent pressure ulcers. Also, in adequate treatment activities, we found no significant difference. Overall, we found a significant decrease in hospital-acquired pressure ulcer frequency from 18 to 13% (P = 0.003) after 4 months and 11% (P < 0.001) after 11 months. CONCLUSION: The number of pressure ulcer patients in hospital can successfully be reduced. General measures such as the introduction of adequate mattresses and guidelines for prevention and treatment are promising tools in this respect.     

Could habits hold the key to weight loss maintenance? A narrative review

Despite the significance placed on lifestyle interventions for obesity management, most weight loss is followed by weight regain. Psychological concepts of habitual behaviour and automaticity have been suggested as plausible explanations for this overwhelming lack of long‐term weight loss success. Interventions that focus on changing an individual's behaviour are not usually successful at changing an individual's habits because they do not incorporate the strategies required to break unhealthy habits and/or form new healthy habits. A narrative review was conducted and describes the theory behind habit formation in relation to weight regain. The review evaluated the effectiveness of using habits as tools to maintain weight loss. Three specific habit‐based weight loss programmes are described: ‘10 Top Tips’, ‘Do Something Different’ and ‘Transforming Your Life’. Participants in these interventions achieved significant weight loss compared to a control group or other conventional interventions. Habit‐based interventions show promising results in sustaining behaviour change. Weight loss maintenance may benefit from incorporating habit‐focused strategies and should be investigated further.