The uptake of the international pressure ulcer/injury prevention and treatment guidelines in the scientific literature: A systematic analysis of two major citation databases

BackgroundThe European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance developed international Clinical Practice Guidelines of the prevention and treatment of pressure ulcers/injuries in 2009, 2014, and 2019. Despite substantial dissemination efforts, evidence about guideline dissemination and uptake in the international literature is lacking.AimThe aim of this review was to capture to the greatest detail possible the number of the citations of the three published Clinical Practice Guidelines.MethodsThe citation databases Web of Science and Scopus were searched for citations of the 2009, 2014 and 2019 Clinical Practice Guidelines including all derivative products including short versions and translations. Two separate search strategies were iteratively developed to ensure highest sensitivity.ResultsThe Cited Reference Search in Web of Science identified hundreds of different referencing formats with more than 2000 citing articles. The Scopus search revealed 250 different reference formats and more than 2000 citation counts. After publication there was a gradual increase of citations that peaks approximately after four years.ConclusionThe three Clinical Practice Guidelines including all derivate versions had a substantial uptake in the scientific literature. This supports the assumption that the guideline dissemination strategies were and are successful.     

Reliability and validity of the Turkish version of pressure ulcer knowledge assessment tool-updated version (PUKAT 2.0)

ObjectiveThis study aimed to determine the reliability and validity of the Turkish version of the measurement tool developed and updated by Manderlier et al. to evaluate the nurses’ evidence-based knowledge about pressure ulcers.Materials and methodsA methodological study design was used. The instrument was translated to Turkish and back-translated to English. A group of faculty members, including physicians and nurses who are experts in the subject area, evaluated the content validity of the tool with the Lawshe technique. A group of 240 nurses who met the inclusion criteria were reached, and then a pilot study was conducted with 35 nurses by using the test-retest method to determine the invariance of the tool over time. The nurses in the pilot study were excluded from the overall sample, and the evaluations were performed with 205 nurses. Item difficulty index and discrimination index were used for the validity of the items since they were multiple-choice items; Kuder-Richardson 20 analysis was used to determine the internal consistency.ResultsThe translated and modified instrument demonstrated acceptable psychometric properties as follows: 1) overall content validity index was 0.90, 2) overall test-retest reliability was 0.83 (0.70–0.92 for the sub-themes), 3) item difficulty indexes were 35–75%, 4) discrimination indexes were 0.44–0.92, and 5) overall Cronbach's alfa for the internal consistency was 0.72.ConclusionsSimilar to the earlier version, the Turkish version of PUKAT 2.0 was demonstrated to be a valid and reliable tool to evaluate the nurses’ knowledge of evidence-based current information about pressure ulcers.     

Validity and reliability of Japanese version of the pressure ulcer knowledge assessment tool

AimTo develop Japanese version of the pressure ulcer knowledge assessment tool, a tool for measuring nurses’ pressure ulcer knowledge to effectively evaluate the efficacy of current educational programs, resulting in prevention and early treatment, and to verify its validity and reliability among Japanese nurses.Materials and methodsA total of 1716 nurses across three university hospitals participated in this study. All had been employed for at least one year. Managers, part-timers, and those in the operating room and the outpatient ward were excluded from the study as it is limited to bedside preventive care.The original tool was translated into Japanese using the Brislin's translation model. A cross-sectional study was used to examine the reliability and validity of the measure within a Japanese sample. Assessment of the multiple-choice test items included analysis of the validity (item difficulty and discriminating index), construct validity, internal consistency, and stability (test–retest reliability).ResultsThe item difficulty indices ranged from 0.17 to 0.95, whereas values for item discrimination ranged from 0.15 to 0.45. Known group validity of the scale was confirmed; therefore, the higher-expertize group consisting of wound, ostomy, and continence nurses significantly outperformed nurses certified in other fields. The overall internal consistency reliability was 0.86 with a two-week test–retest intraclass correlation of 0.60.ConclusionsThe instrument may be applied as a reliable and valid measure to assess nurses’ pressure ulcer knowledge in the fields of nursing education, research, and practice in Japan.     

Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019

Aim

The European Pressure Ulcer Advisory Panel, the Pan Pacific Pressure Injury Alliance, and the National Pressure Ulcer Advisory Panel are updating the ‘Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline’ (CPG) in 2019. The aim of this contribution is to summarize and to discuss the guideline development protocol for the 2019 update.

Validity and reliability of the Turkish version of the pressure injury knowledge assessment tool 2.0

AimThe aim of this study was to develop a Turkish version of the Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT 2.0) and determine its validity and reliability.Materials and MethodsThis was a cross-cultural adaptation and validation study. The study sample included a total of 451 participants (232 nurses and 219 nursing students). The validity of the Turkish version of the PUKAT 2.0 was evaluated with linguistic validity, content validity, item validity (item difficulty, discriminating index), and construct validity (known-groups technique) analyses. The reliability of the tool was evaluated by conducting a test–retest analysis.ResultsContent validity index (CVI) for the items (Item-CVI) ranged from 0.83 to 1.00 and the CVI for the scale (Scale-CVI) was 0.95. The difficulty index for 21 items ranged from 0.10 to 0.63. Four items were found to be too difficult. Item discriminating index values ranged from 0.00 to 0.61. The overall intraclass correlation coefficient (ICC) was found to be 0.80.ConclusionThe Turkish version of the Pressure Injury Knowledge Assessment Tool 2.0 (PIKAT 2.0-Tr) is supported by acceptable psychometric properties and can be used to evaluate the knowledge of nurses and nursing students in Turkey about the prevention of PI.     

Adaptation of a MR imaging protocol into a real-time clinical biometric ultrasound protocol for persons with spinal cord injury at risk for deep tissue injury: A reliability study

BackgroundHigh strain in soft tissues that overly bony prominences are considered a risk factor for pressure ulcers (PUs) following spinal cord impairment (SCI) and have been computed using Finite Element methods (FEM). The aim of this study was to translate a MRI protocol into ultrasound (US) and determine between-operator reliability of expert sonographers measuring diameter of the inferior curvature of the ischial tuberosity (IT) and the thickness of the overlying soft tissue layers on able-bodied (AB) and SCI using real-time ultrasound.Material and methodsPart 1: Fourteen AB participants with a mean age of 36.7 ± 12.09 years with 7 males and 7 females had their 3 soft tissue layers in loaded and unloaded sitting measured independently by 2 sonographers: tendon/muscle, skin/fat and total soft tissue and the diameter of the IT in its short and long axis. Part 2: Nineteen participants with SCI were screened, three were excluded due to abnormal skin signs, and eight participants (42%) were excluded for abnormal US signs with normal skin. Eight SCI participants with a mean age of 31.6 ± 13.6 years and all male with 4 paraplegics and 4 tetraplegics were measured by the same sonographers for skin, fat, tendon, muscle and total. Skin/fat and tendon/muscle were computed.ResultsAB between-operator reliability was good (ICC = 0.81–0.90) for 3 soft tissues layers in unloaded and loaded sitting and poor for both IT short and long axis (ICC = −0.028 and −0.01). SCI between-operator reliability was good in unloaded and loaded for total, muscle, fat, skin/fat, tendon/muscle (ICC = 0.75–0.97) and poor for tendon (ICC = 0.26 unloaded and ICC = −0.71 loaded) and skin (ICC = 0.37 unloaded and ICC = 0.10).ConclusionA MRI protocol was successfully adapted for a reliable 3 soft tissue layer model and could be used in a 2-D FEM model designed to estimate soft tissue strain as a novel risk factor for the development of a PU.     

Nurses' knowledge and practice of pressure ulcer prevention and treatment: An observational study

Aims and objectivesTo assess nurses' knowledge on pressure ulcer (PU) prevention and treatment in Jordan, and the frequency of and factors influencing nurses’ implementation of PU prevention and treatment interventions.BackgroundHighly educated and experienced nurses can provide effective PU care; however, previous studies highlighted poor knowledge and implementation of PU care.DesignA correlational study examining nurses’ knowledge of PU prevention and frequency of PU preventive actions in Jordanian hospitals.MethodsParticipants were 377 nurses and 318 patients from 11 hospitals. Data were collected to quantify the frequency of nurses’ implementation of pressure ulcer prevention and treatment interventions for patients suffering from PUs and/or at risk of PU development using a self-reported cross-sectional survey and prospective 8-h observation.ResultsFor observed PU prevention while type of hospital and number of beds in units were significant it is not known without further work if this is replicable. For observed PU treatment, linear regression analysis revealed significant negative beta values for more than 50 beds in clinical unit (β = −2.49).ConclusionThe study addressed new factors, facilitating the provision of prevention and treatment strategies to PU development, including type of clinical institution and number of beds in clinical unit.Relevance to clinical practiceThere is a need to develop training programmes to improve insufficient nurses’ knowledge and, thus, clinical practices on PU prevention and treatment. These programmes would assist both junior and senior nurses and other key stakeholders (e.g. hospital managers, policy-makers, and educators) to improve the performance of PU services, thus, minimising patient suffering.     

The validity and reliability of the Pressure Ulcer Quality of Life instrument: A methodological study

AimThis study aimed to adapt the Pressure Ulcer Quality of Life instrument to Turkish and to determine the validity and reliability by using the Rasch model.Materials and methodsThis methodological study used forward translation, expert opinion, back translation, pilot testing, and finalization for the language adaptation of the instrument. Prior to back translation, the instrument was assessed by five experts certified in wound care nursing. Then, the comprehensibility of the instrument was tested in the pilot study. The study was conducted between March 2017 and September 2019 at one private, one state, and four university hospitals in Turkey. Eligible participants were patients 18 years of age or older, having pressure injury, and fully conscious. Data were collected from a total of 250 patients by using a demographic and clinical history form, the Pressure Ulcer Quality of Life instrument, and the World Health Organization Quality of Life - Brief Form Turkish scale. The instrument's internal construct validity using the Rasch model, the external construct validity, internal consistency, and test-retest reliability were assessed.ResultsThe final Turkish version of the Pressure Ulcer Quality of Life self-report instrument differed from the original, comprising 74 items under the following ten subscales: three regarding symptoms, plus one itchiness item; four regarding physical functioning; two regarding psychological well-being, self-consciousness, and appearance; and one regarding social participation.ConclusionThe Turkish version of the PU-QOL is a valid, reliable, and widely available instrument for measuring quality of life for patients with pressure injury.     

TexiCare: An innovative embedded device for pressure ulcer prevention. Preliminary results with a paraplegic volunteer

This paper introduces the recently developed TexiCare device that aims at preventing pressure ulcers for people with spinal cord injury. This embedded device is aimed to be mounted on the user wheelchair. Its sensor is 100% textile and allows the measurement of pressures at the interface between the cushion and the buttocks. It is comfortable, washable and low cost. It is connected to a cigarette-box sized unit that (i) measures the pressures in real time, (ii) estimates the risk for internal over-strains, and (iii) alerts the wheelchair user whenever necessary. The alert method has been defined as a result of a utility/usability/acceptability study conducted with representative end users. It is based on a tactile-visual feedback (via a watch or a smartphone for example): the tactile modality is used to discreetly alarm the person while the visual modality conveys an informative message. In order to evaluate the usability of the TexiCare device, a paraplegic volunteer equipped his wheelchair at home during a six months period. Interestingly, the first results revealed bad habits such as an inadequate posture when watching TV, rare relief maneuvers, and the occurrence of abnormal high pressures.     

Development and preliminary validation of a tool measuring concordance and belief about performing pressure-relieving activities for pressure ulcer prevention in spinal cord injury

ObjectiveTo develop and examine the reliability, and validity of a questionnaire measuring concordance for performing pressure-relief for pressure ulcer (PrU) prevention in people with Spinal Cord Injury (SCI).MethodsPhase I included item development, content and face validity testing. In phase II, the questionnaire was evaluated for preliminary acceptability, reliability and validity among 48 wheelchair users with SCI.ResultsThirty-seven items were initially explored. Item and factor analysis resulted in a final 26-item questionnaire with four factors reflecting concordance, perceived benefits, perceived negative consequences, and personal practical barriers to performing pressure-relief activities. The internal consistency reliability for four domains were very good (Cronbach's α = 0.75-.89). Pearson correlation coefficient on a test-retest of the same subjects yielded significant correlations in concordance (r² = 0.91, p = .005), perceived benefit (r² = 0.71, p < .04), perceived negative consequences (r² = 0.98, p < .0001), personal barriers (r² = 0.93, p= .002). Participants with higher levels of concordance reported a greater amount of pressure-relieving performed. Individuals viewing PrU as a threatening illness were associated with higher scores of concordance and tended to report a greater amount of pressure-relieving performance which provides evidence of criterion related validity.ConclusionThe new questionnaire demonstrated good preliminary reliability and validity in people with SCI. Further evaluation is necessary to confirm these findings using larger samples with follow-up data for predictive validity. Such a questionnaire could be used by clinicians to identify high risk of patients and to design individualised education programme for PrU prevention.     

“Doctor,how long will it take?” Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury

BackgroundFlap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors.MethodsThis observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure.Results85 patients were included. Median healing time was 48 days (R: 20–406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02).ConclusionAfter primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.     

Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review

AimsTo undertake an integrative literature review to identify, analyse and synthesize current literature on the Kennedy terminal ulcer (KTU) and other unavoidable skin injuries that appear at the end of life regardless of the healthcare context in which they occur.MethodsIntegrative review following the Whittemore and Knafl methodology.The search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. It was limited to articles in English, French, Portuguese and Spanish. As there is little scientific production on the subject, no restrictions were applied regarding publication date.ResultsOnly 17 articles met the inclusion criteria. These articles were reviewed and analysed. Four relevant issues emerged: Skin failure, SCALE, Kennedy Terminal Ulcer, Trombley-Brennan: different names for the same problem; the defining characteristics and physiopathology of KTU; the differences between KTU and other injuries; and the care approach for KTU and other unavoidable injuries at the end of life.ConclusionsWe identified gaps regarding the physiopathology of KTU since the current knowledge is based only on hypotheses. There is also a large gap in the knowledge about care approaches, perhaps because care plans are not recorded. Despite this, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life.     

Knowledge of nurses and nursing assistants about pressure ulcer prevention: A survey in 16 Belgian hospitals using the PUKAT 2.0 tool

Background

Pressure ulcers have a high impact on patients and their families. Profound and up-to-date knowledge among nurses is important given the effect on attitudes and preventative behaviour. To gain insight into educational needs and priorities, regular knowledge assessments are needed.

An extracellular matrix graft (Oasis® wound matrix) for treating full-thickness pressure ulcers: A randomized clinical trial

Aim

The purpose of the study was to evaluate clinical safety and effectiveness of Oasis^® Wound Matrix as a treatment for full-thickness pressure ulcers and compare it to Standard Care.

Pressure ulcer induced by discontinuation of levodopa: Case report of an older patient with Parkinson's disease

We report the case of a pressure ulcer that developed consequent to the discontinuation of levodopa (L-3,4-dihydroxyphenylalanine) administration. The 86-year-old female patient had a 5-year history of Parkinson's disease treated with levodopa. She developed a sacral pressure ulcer due to unanticipated immobilization induced by the discontinuation of levodopa. Discontinuation of mandatory drugs is therefore a risk factor for the development of pressure ulcers in patients with Parkinson's disease.     

Pressure ulcer incidence and Braden subscales: Retrospective cohort analysis in general wards of a Portuguese hospital

AimTo study the influence of Braden subscales scores (at the first pressure ulcer risk assessment) on pressure ulcer incidence using a univariate and a multivariate time to event analysis.Materials and methodsRetrospective cohort analysis of electronic health record database from adult patients admitted without pressure ulcer(s) to medical and surgical wards of a Portuguese hospital during 2012. The hazard ratio of developing a pressure ulcer during the length of inpatient stay was calculated by univariate Cox regression for each variable of interest and by multivariate Cox regression for the Braden subscales that were statistically significant.ResultsThis study included a sample of 6552 participants. During the length of stay, 153 participants developed (at least) one pressure ulcer, giving a pressure ulcer incidence of 2.3%. The univariate time to event analysis showed that all Braden subscales, except “nutrition”, were associated with the development of pressure ulcer. By multivariate analysis the scores for “mobility” and “activity” were independently predictive of the development of pressure ulcer(s) for all participants.Conclusion(Im)“mobility” (the lack of ability to change and control body position) and (in)“activity” (the limited degree of physical activity) were the major risk factors assessed by Braden Scale for pressure ulcer development during the length of inpatient stay. Thus, the greatest efforts in managing pressure ulcer risk should be on “mobility” and “activity”, independently of the total Braden Scale score.     

Pressure injury and risk in the inpatient paediatric and neonatal populations: A single centre point-prevalence study

IntroductionPrevention and management of pressure injury is a key nurse-sensitive quality indicator. From clinical insights, pressure injury effects hospitalised neonates and children, however it is unclear how prevalent this is. The aim of this study was to quantify prevalence of pressure injury, assess skin integrity risk level, and quantify preventive interventions in both neonatal and child inpatient populations at a large children's hospital in the UK.MethodsA cross-sectional study was undertaken, assessing the skin integrity of all children allocated to a paediatric or neonatal bed in June/July 2020. A data collection tool was adapted from two established pressure ulcer point prevalence surveys (EUPAP and Medstrom pre-prevalence survey). Risk assessment was performed using the Braden QD scale.ResultsEighty-eight participants were included, with median age of 0.85 years [range 0–17.5 years), with 32 (36%) of participants being preterm. Median length of hospital stay was 11 days [range 0–174 days]. Pressure ulcer prevalence was 3.4%. The majority of participants had at least two medical devices, with 16 (18.2%) having more than four. Having a medical device was associated with increased risk score of developing pressure injury (odds ratio [OR] 0.03, 95% Confidence Interval [CI] 0.01–0.05, p = 0.02). Most children (39 (44%)) were reported not having proposed preventive measures in place aligned to their risk assessment. However, for those that did, 2 to 4 hourly repositioning was associated with a risk reduction on pressure damage (OR 0.13, 95% CI 0.03–0.23, p = 0.01).ConclusionOverall, we found a low prevalence of pressure injury across preterm infants, children and young people at a tertiary children's hospital. Accurate risk assessment as well as availability and implementation of preventive interventions are a priority for healthcare institutes to avoid pressure injury.