The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence

BACKGROUND: In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study. AIM: Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee]. METHOD: A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions. RESULTS: Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities. CONCLUSION: It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

Cigarette smoking and risk of pressure ulcer in adult intensive care unit patients

The objective of this study was to assess relationship between smoking, some other risk factors and ulcers development in intensive care unit. This prospective cohort study was performed in two university‐affiliated hospitals. The sample consisted of adult male patients who were admitted to medical–surgical intensive care units. All eligible patients were grouped according to their cigarette smoking status as smoker and non‐smoker. The final sample included 160 smokers and 192 non‐smokers. Pressure ulcer occurred in 62 smoker patients and 28 of non‐smoker who showed significant difference. Also number of pack‐year of cigarettes smoking showed significant association with ulcer development. Ulcer stage was significantly different between the two groups. Besides of smoking, age, length of stay, faecal incontinency, diabetes mellitus, anaemia and trauma were significantly associated with pressure ulcers. Our study showed significant association between smoking and development of pressure ulcers.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers are a potential complication for intensive care patients and their prevention is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.     

Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study

Background

Pressure ulcers are common in acute and long-term care. However, critically ill patients usually have multiple risk factors for pressure ulcers.

Objectives

The study was conducted to assess pressure ulcer incidence in intensive care patients, the factors related to pressure ulcer incidence and the course of pressure ulcers after the admission to an intensive care unit.

Design

A longitudinal design.

Setting

This study was carried out in cardiological and surgical intensive care of a general hospital and in a nephrological intensive care of a university hospital.

Participants

All patients admitted to intensive care wards during the period from April until October 2006 were invited to take a part in the study. One hundred and twenty-one patients were involved in the study. The inclusion criteria were adult intensive care patients, males and females, all diagnosis were included. The exclusion criterion was patients whose age less than 18 years.

Method

Each patient was assessed twice; first, upon admission and second upon discharge or death, or after 2 weeks if the patient was still in intensive care. The assessed data included pressure ulcer preventive measures, risk factors using Braden score, pressure ulcer characteristics and treatment. Additionally, incontinence supplies (urine/bowel) if used and the severity of illness using Acute Physiology and Chronic Health Evaluation (APACHE II score) were assessd.

Results

This study revealed a total incidence of 3.3% (4.5% in nephrological patients and 2.9% in surgical patients). Sixteen patients with a total of 21 pressure ulcers were admitted to the intensive care units. During the patients’ stay at the intensive care units six pressure ulcers developed newly and five pressure ulcers healed. The mean of the APACHE II score of patients with new pressure ulcers (16.6) were higher than in patients without new pressure ulcers (11.5).

Conclusion

Pressure ulcer incidence is low in this study compared to other studies. Pressure ulcers can be healed in intensive care patients. Using some preventive measures such as foam and alternating air pressure mattresses may help to decrease pressure ulcer development. Hydrocolloid dressing may help to increase the healing rate of pressure ulcers.     

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. Design. A prospective cohort study. Method. A total of 197 subjects in a 106‐bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Results. Out of 197 subjects, 18 patients (9·1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0·736 and for the Braden scale was 0·648. The modified Braden cut‐off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = ?1·544, OR=0·214, p = 0·016), body build for height (Beta = ?0·755, OR = 0·470, p = 0·030) and skin type (Beta = ?1·527, OR = 0·217, p = 0·002) were significantly predictive of pressure ulcer development. Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.     

Prevention of heel pressure ulcers among older patients – from ambulance care to hospital discharge: A multi-centre randomized controlled trial

The aim was to investigate the effect of an early intervention, a heel suspension device boot, on the incidence of heel pressure ulcers among older patients (aged 70 +).BackgroundPressure ulcers are a global healthcare issue; furthermore, the heel is an exposed location. Research indicates that preventive nursing interventions starting during the ambulance care and used across the acute care delivery chain are seldom used.MethodsA multi-centre randomized control study design was used. Five ambulance stations, two emergency departments and 16 wards at two Swedish hospitals participated. Altogether, 183 patients were transferred by ambulance to the emergency department and were thereafter admitted to one of the participating wards.ResultsSignificantly fewer patients in the intervention group (n=15 of 103; 14.6%) than the control group (n=24 of 80; 30%) developed heel pressure ulcers during their hospital stay (p=0.017).ConclusionsPressure ulcer prevention should start early in the acute care delivery chain to increase patient safety.     

Staffing and the incidence of pressure ulcers in German hospitals: A multicenter cross‐sectional study

In this study, we investigated the association between nurse and physician staffing and the incidence of hospital‐acquired pressure ulcers in acute care hospitals in Germany. The study population, derived from the Quality Reports of German Hospitals and the Hospital Directory, consisted of 710 hospitals covering 716,281 cases in the first quarter of 2010, and 672 hospitals covering 757,665 cases in the first quarter of 2012. The relationship between staffing variables and the standardized incidence ratios of pressure ulcers was examined using bivariate and multivariable linear regression models. Estimates were controlled for several patient and hospital characteristics. The total number of nurses and physicians per 100 beds did not show significant associations with outcome variables. However, the proportion of nurses with at least 3 years of training to total nursing staff was inversely associated with the incidence of pressure ulcers at hospital level, indicating a higher efficacy of pressure ulcer‐prevention measures.     

Predicting pressure ulcer risk: a multifactorial approach to assess risk factors in a large university hospital population

Aims. The purpose of this study was: (1) to determine the combination of risk factors which best predicts the risk of developing pressure ulcers among inpatients in an acute care university hospital; (2) to determine the appropriate weight for each risk factor; and (3) to derive a concise and easy‐to‐use risk assessment tool for daily use by nursing staff. Background. Efficient application of preventive measures against pressure ulcers requires the identification of patients at risk. Adequate risk assessment tools are still needed because the predictive value of existing tools is sometimes unsatisfactory. Design. Survey. Methods. A sample of 34,238 cases admitted to Essen University Clinics from April 2003 and discharged up to and including March 2004, was enrolled into the study. Nursing staff recorded data on pressure ulcer status and potential risk factors on admission. Predictors were identified and weighted by multivariate logistic regression. We derived a risk assessment scale from the final logistic regression model by assigning point values to each predictor according to its individual weight. Results. The period prevalence rate of pressure ulcers was 1·8% (625 cases). The analysis identified 12 predictors for developing pressure ulcers. With the optimum cut‐off point sensitivity and specificity were 83·4 and 83·1%, respectively, with a positive predictive value of 8·4% and a negative predictive value of 99·6%. The diagnostic probabilities of the derived scale were similar to those of the original regression model. Conclusions. The predictors mostly correspond to those used in established scales, although the use of weighted factors is a partly novel approach. Both the final regression model and the derived scale show good prognostic validity. Relevance to clinical practice. The derived risk assessment scale is an easy‐to‐understand, easy‐to‐use tool with good prognostic validity and can assist in effective application of preventive measures against pressure ulcer.     

Risk factors and prevention among patients with hospital-acquired and pre-existing pressure ulcers in an acute care hospital

Aims and objectives.  This study aimed to describe and identify risk factors associated with hospital‐acquired pressure ulcers among adults in an acute care hospital compared with patients with pre‐existing pressure ulcers present on admission. A further aim was to identify the preventive measures performed with both groups respectively. Background.  Pressure ulcers occur most often in older and immobile persons with severe acute illness and neurological deficits. However, few studies have addressed risk factors that are associated with hospital‐acquired pressure ulcers compared with patients with pre‐existing pressure ulcers. Design.  A point prevalence study with a cross‐sectional survey design was conducted at a Swedish university hospital. Method.  Data on 535 patients were recorded using a modified version of the protocol developed and tested by the European Pressure Ulcer Advisory Panel, including the Braden scale for risk assessment. Results.  The prevalence of pressure ulcers was 27% (95% confidence interval, 23–31%). Higher age and a total Braden score below 17 were significantly associated with the presence of pressure ulcers. Among individual risk factors higher age, limited activity level and friction and shear while seated or lying down were associated with hospital‐acquired pressure ulcers, whereas only higher age and friction and shear were associated with the presence of pressure ulcers in the overall sample. There was an overall sparse use of preventive measures to relieve pressure. Conclusion.  The findings of the present study revealed that pressure ulcers and the insufficient use of preventive measure to relieve pressure is still a problem in acute care settings. A continued focus must be placed on staff training in identifying patients at risk for pressure ulcers development. Relevance to clinical practice.  Increasing the ability to identify patients who are at risk for pressure ulcer development can assist in preventing unnecessary complications and suffering as well as reduce costs.     

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross‐sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6·8%. The age‐, sex‐ and risk‐standardized prevalence per regional department varied between 4·9% and 9·1%. Of the 744 subjects at risk, 33 (4·4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64·8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30·8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4·8% adherence, 76·6% no adherence and 18·6% no prevention. A proportion of 22·2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21·4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.     

Linking RN workgroup job satisfaction to pressure ulcers among older adults on acute care hospital units

We examined the relationship between registered nurse (RN) workgroup job satisfaction and hospital‐acquired pressure ulcers (HAPUs) among older adults on six types of acute care units. Random‐intercept logistic regression analyses were performed using 2009 unit‐level data from the National Database of Nursing Quality Indicators® (NDNQI®) and the NDNQI RN Survey. Overall, RN workgroup job satisfaction was negatively associated with HAPU rates, although the relationship varied by unit type. RN workgroup satisfaction was significantly associated with HAPU rates on critical care, medical, and rehabilitation units. No significant association was found on step‐down, surgical, and medical‐surgical units. Findings provide evidence that higher RN workgroup job satisfaction is related to lower HAPU rates among older adult patients in acute care hospitals. © 2013 Wiley Periodicals, Inc. Res Nurs Health 36:181–190, 2013     

Comparison of two skin examination methods for grade 1 pressure ulcers

Aims and objectives. The purpose of this study was to find out whether the application of a transparent device for diagnosing grade 1 pressure ulcers influences grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Background. It is assumed that the accuracy of visual grade 1 pressure ulcer diagnosis is enhanced if a transparent device is used. Design. Quasi‐experimental. Method. Within a pressure ulcer prevalence study participating institutions were divided into groups at random. Data collecting nurses of the intervention group (n = 4667) applied a transparent disc. Data collecting nurses of the control group (n = 5095) conducted skin inspection using the ‘finger‐method’. Group comparisons were conducted. Relations between skin assessment methods and grade 1 pressure ulcer prevalence was analysed by logistic regressions. Results. Both groups were comparable regarding demographic characteristics. Grade 1 pressure ulcer prevalence in the intervention group was 3·9% and 7·1% in the control group (p<0·001). The total number of observed grade 1 pressure ulcers was 282 (intervention group) and 555 (control group). The chance to identify at least one grade 1 pressure ulcer increased when the ‘finger method’ was used (p<0·001). Conclusions. The use of a transparent disc influences the grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Relevance to clinical practice. Accurate identification of grade 1 pressure ulcers is important, because the development of those skin alterations indicate an urgent need for preventive measures. As the diagnosis of grade 1 pressure ulcers seems to be affected by the observation method, it is unknown which method is the more accurate. A study of diagnostic accuracy is needed to answer this question. It is recommended to report pressure ulcer prevalence rates including and excluding grade 1.     

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers

Aims and objective. The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2–4) in nursing home patients with non‐blanchable erythema. Background. No studies could be found that identify risk factors for further development of pressure ulcer in patients with non‐blanchable erythema. For some patients with non‐blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. Design. Secondary data analyses of a previously conducted randomised controlled trial were performed. Methods. Eighty‐four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non‐blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. Results. The cumulative pressure ulcer incidence was 18·7% (44/235). Hypotension (relative risk = 3·42, 95% CI = 1·56–7·49), a history of a cerebral vascular accident (relative risk = 1·94, 95% CI = 1·10–3·70) and contractures (relative risk = 2·02, 95% CI 1·03–3·95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. Conclusions. In nursing home residents with non‐blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. Relevance to clinical practice. Patients with non‐blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.     

Drug use and pressure ulcers in long‐term care units: do nurse time pressure and unfair management increase the prevalence?

Aims. This study examined the associations between nurse working conditions (time pressure and perceived unfair management) and quality indicators (prevalence of antianxiety or hypnotic drug use and pressure ulcers) in long‐term care units. Background. Differences persist across long‐term care facilities in their care processes and resident outcomes even after adjusting for residents’ clinical conditions. Little is known about how nurses’ working conditions influence the quality of care. Design. Survey. Methods. Data on working conditions were drawn in 2002 from 724 nurses in 66 long‐term care units that reported quality indicators based on the Resident Assessment Instrument system as measured by Minimum Data Set. Percentage change in the quality indicators from 2002 were estimated using hierarchical multiple regression analyses with adjustments made for the baseline quality indicators (2001) and unit structural factors (unit size and staffing level). Results. Unit time pressure increased the prevalence of both quality problems (p‐values <0·05). Perceived unfair management was related to increased drug use (p = 0·038). Conclusions. The findings of this research suggest that quality of care can be improved by enhancing nurse working conditions. Relevance to clinical practice. Organisational initiatives should be aimed at reducing time pressures and promoting fair managerial procedures that engage all nursing staff in the decision‐making in long‐term care settings.     

Explication of the construct of shared care and the prevention of pressure ulcers in home health care

The purpose of this investigation was to render a more complete understanding of subjective perceptions of pressure ulcers from the perspective of family dyads, and to study the effect of these subjective experiences on preventive behaviors and pressure ulcer outcomes. A naturalistic inquiry, combined with objective measures, was used. Twenty-one dyads participated in four in-depth interviews to explore how they mentally represented and responded to the risk of pressure ulcers. Through the process of concept development, a lay representation of pressure ulcers was developed. This process produced a new concept, identified as “shared care,” that explained how the dyad's interaction influenced preventive behavior. Shared care consists of three elements: communication of symptoms, decisions about how to respond to symptoms, and appraisals of reciprocity. Two contrasting patterns of care were identified: shared and directed/discrepant. In the shared care group, 10 patients were at risk for pressure ulcers but only 4 developed ulcers. In this discrepant care group, 3 patients were at risk and 2 developed pressure ulcers. Shared care was a pattern of interaction used successfully by family members to prevent pressure ulcers in patients at risk. © 1996 John Wiley & Sons, Inc.     

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

Aim To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. Methods A cross‐sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. Results The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure‐reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%). Conclusions Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence‐based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.