Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact

OBJECTIVE: To investigate the characteristics, predictors, and consequences of pressure ulcers in patients with nontraumatic spinal cord injury (SCI). DESIGN: Retrospective, 3-year, case series. SETTING: Tertiary medical unit specializing in SCI rehabilitation. PARTICIPANTS: Consecutive sample of 134 adult inpatient referrals with nontraumatic SCI. Patients requiring initial rehabilitation or readmission were included. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcome measures were presence of pressure ulcers on admission to rehabilitation, incidence of new pressure ulcers developing during hospitalization, and any complications attributable to pressure ulcers during inpatient rehabilitation. Secondary objectives were to examine the predictability of risk factors for pressure ulcers, to assess the usefulness of a model previously developed for predicting pressure ulcers in patients with chronic SCI, and to estimate the effect of pressure ulcers on rehabilitation of nontraumatic SCI. RESULTS: Prevalence of pressure ulcers among admissions was 31.3% (n=42). Only 2.2% (n=3) of patients developed a new pressure ulcer after admission. The length of stay (LOS) of patients admitted with a pressure ulcer was significantly longer than that of those without a pressure ulcer (geometric mean, 62.3 d for pressure ulcer vs 28.2 d for no pressure ulcer, P=.0001). Many previously identified risk factors for pressure ulcers in SCI patients did not apply to our nontraumatic SCI patients. It is estimated that the inpatient LOS for those patients with a significant pressure ulcer was increased by 42 days. CONCLUSIONS: Pressure ulcers are a common complication for people with nontraumatic SCI who are admitted for rehabilitation, and they have a significant impact on LOS.     

Patterns of recurrent pressure ulcers after spinal cord injury: identification of risk and protective factors 5 or more years after onset

OBJECTIVES: To identify risk and protective factors associated with a history of recurrent pressure ulcers among participants with spinal cord injury (SCI). DESIGN: A mail survey was used to identify factors associated with the presence or absence of recurrent pressure ulcers. SETTING: A large specialty hospital in the southeastern United States. PARTICIPANTS: All participants had traumatic SCI, were nonambulatory, 18 years or older, and had been injured at least 5 years. A total of 826 subjects participated, 633 of whom reported a pressure ulcer history that could be classified as to whether they did or did not have a history of recurrent pressure ulcers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: History of pressure ulcers was measured by a single item that required participants to classify their history into 1 of 5 options, ranging from never having any pressure ulcers to having almost continuous pressure ulcers, often requiring hospitalization. Those who either never had a pressure ulcer or had them mostly for a short period after SCI onset were classified as nonrecurrent, whereas those who reported at least 1 per year were classified as recurrent. RESULTS: Seventy percent of the participants failed to report recurrent pressure ulcers (never had any or had them only immediately after SCI onset), whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year. Logistic regression analyses suggested several general behaviors were protective for recurrent pressure ulcers, including lifestyle, exercise, and diet. Yet none of the behaviors generally recommended during inpatient rehabilitation specifically to prevent pressure ulcers (eg, skin checks weight shifts) were associated with pressure ulcer history. Only 2 risk behaviors were identified (number of cigarettes smoked, use of medication for sleep), although several proxy variables were related to pressure ulcer history. CONCLUSIONS: Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A healthy lifestyle appears to be strongly associated with avoiding pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated. Problem solving and coping strategies should be targets for further research.     

Surgical treatment of pressure ulcers: 20-year experience

OBJECTIVE: To review the outcomes of surgical management of spinal cord injury (SCI) patients with severe pressure ulcers and to examine likely risk factors for recurrence of pressure ulcers. DESIGN: A retrospective medical record review. SETTING: An SCI unit in a tertiary care facility. PATIENTS: All admissions to the SCI unit for grade 4 pressure ulcers from 1976 to 1996. INTERVENTION: Surgical repair of pressure ulcers. MAIN OUTCOME MEASURE: Complication and recurrence rates of pressure ulcers. RESULTS: Of 598 pressure ulcers, 468 were pelvic area ulcers, of which 431 (92%) were treated surgically. Fifty-three had split-thickness skin grafting, and 380 were treated with 421 surgical procedures (253 fasciocutaneous or cutaneous flaps, 93 muscle or musculocutaneous flaps, 75 primary closures). One hundred eight (26%) of these procedures required some bone work. Suture line dehiscence occurred in 130 (31%), with 45 (11%) requiring reconstruction and 8 (2%) requiring skin grafting to heal. At discharge, 38 (9%) of these pelvic ulcers had not healed. Recurrent admissions occurred in 90 (54%) of the patients. Recurrence of ulcers at the same site occurred in 31% of the total number of ulcers and at a different site in 21%. At the time of the 415 admissions, 336 (81%) of the patients were unemployed; 159 (38%) had grade 8 or lower level of education; and 226 (55%) lived alone or with family but were independent in self-care. Of the 168 patients studied, 45 (27%) were aboriginal (Canadian native), and 59 (35%) had a history of drug or alcohol abuse. CONCLUSIONS: The vast majority of severe pressure ulcers were surgically treated. Complication and recurrence rates are similar to previous reports. Psychosocial problems (unemployment, low level of education, drug or alcohol abuse, poverty in the native communities) appear to increase the risk for pressure ulcer development.     

Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit

BACKGROUND: Critically ill patients are at increased risk for pressure ulcers, which increase patients' morbidity and mortality. Quality improvement projects decrease the frequency of pressure ulcers. OBJECTIVES: To improve patients' outcomes by reducing the prevalence of pressure ulcers, identifying areas for improvement in prevention of pressure ulcers, and increasing the adoption of preventive strategies in an intensive care unit. METHOD: Quasi-experimental methods were used for this quality improvement project in which 563 surveys of patients' skin were performed during 22 audits conducted during a 26-month period. One-on-one clinical instruction was provided to bedside nurses during the surveys, and pressure ulcer data were displayed in the clinical area. RESULTS: The frequency of pressure ulcers of all stages showed an overall downward trend, and the prevalence decreased from 50% to 8%. The appropriate allocation of pressure-relieving devices increased from 75% up to 95% to 100%. The likely origin of the ulcer (ie, whether it was hospital or community acquired) and the anatomical site of the pressure ulcers did not change during the study period. CONCLUSIONS: This program was successful in reducing the prevalence of pressure ulcers among vulnerable intensive care patients and indicates that quality improvement is a highly effective formula for improving patients' outcomes that is easily implemented by using clinical expertise and existing resources.     

Characteristics of burn patients developing pressure ulcers

In 1997 a prospective study to identify pressure ulcer development and identify risk factors was conducted on 217 consecutive patients in the burn center. Weekly rounds were conducted, and the specifics of pressure ulcer development, demographics, concurrent injuries, comorbid conditions, risk factors, and patient outcomes were identified. An incidence of 4.1% was identified, with the most common locations being the sacrum, occipital area, and heel. All patients with pressure ulcers met criteria for a major burn injury. The patients had concurrent injuries or an infectious process, had more surgical procedures, and were older than the group that did not develop pressure ulcers. A lower Braden Scale for risk assessment and a later onset of ulceration was noted in this population compared with previous studies of nonburn patients. The results of this study have led to changes in our burn clinical pathways that target preventive strategies in high-risk patients.     

Predicting the risk of pressure ulcers in critically ill patients.

BACKGROUND: Critically ill patients are at high risk for pressure ulcers. OBJECTIVES: To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients. METHOD: The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers. RESULTS: A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03). CONCLUSIONS: Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.     

外科重症患者压疮发生高危因素分析

目的：探讨外科重症患者压疮发生相关危险因素,为制定预防压疮的有效措施提供依据。方法：采用自设外科重症患者压疮危险因素调查表收集某三级甲等医院47例外科重症患者资料,将其中发生院内压疮的14例患者设为压疮组,未发生压疮的33例患者设为对照组,两组间对20项指标进行单因素分析及多因素Logistic回归分析,找出压疮发生的危险因素。结果：单因素分析显示,压疮组在ICU住院期间去甲肾上腺素使用总计小时数、动脉血乳酸最高值、机械通气总天数、血液净化治疗天数、排便失禁天数5项指标值高于对照组,差异有统计学意义（P〈0.05）;多因素Logistic回归分析显示,去甲肾上腺素使用总计小时数、动脉血乳酸最高值是压疮发生的高危因素（P〈0.05）。结论：应针对压疮高危人群和危险因素采取有针对性的措施,积极控制原发病,在抢救的同时采取积极的减压措施,以提高危重患者压疮防控的护理质量。     

Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients

OBJECTIVE: To describe the short-term and long-term effects of a hospital-wide pressure ulcer prevention and treatment guideline on both the incidence and the time to the onset of pressure ulcers in critically ill patients. DESIGN: Prospective cohort study. SETTING: Adult intensive care department of a university medical center. PATIENTS: Critically ill patients (n = 399). INTERVENTIONS: A guideline for pressure ulcer care was implemented on all intensive care units. The attention of nurses for timely transfer to a specific pressure-reducing device was an important part of this guideline. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, demographics, pressure ulcer risk profile at admission, daily pressure ulcer grading, and type of mattress were determined to describe the short-term and long-term effects 3 and 12 months after the implementation. The incidence density of pressure ulcers grade II-IV decreased from 54 per 1000 patient days at baseline to 32 per 1000 days (p = .001) 12 months after the implementation. The median pressure ulcer-free time increased from 12 days to 19 days (hazard rate ratio, 0.58; p = .02). After adjustment for differences in risk factors in a Cox proportional hazard model, the number of preventive transfers to special mattresses was the strongest indicator for the decreased risk of pressure ulcers (hazard rate ratio, 0.22; p < .001). The number needed to treat to prevent one pressure ulcer during the first 9 days was six. CONCLUSIONS: The implementation of a guideline for pressure ulcer care resulted in a significant and sustained decrease in the development of grade II-IV pressure ulcers in critically ill patients. Timely transfer to a specific mattress (i.e., transfer before the occurrence of a pressure ulcer) was the main indicator for a decrease in pressure ulcer development.     

Poster 27: Pressure ulcer history and spinal cord injury

Objective: To identify risk and protective factors associated with a history of recurrent pressure ulcers after spinal cord injury (SCI). Design: Cross-sectional. Setting: Large southeastern US specialty hospital. Participants: 826 nonambulatory adults with traumatic SCI of at least 5 years in duration. Interventions: Not applicable. Main Outcome Measures: Outcomes included current pressure ulcers, pressure ulcers within the past years, days adversely impacted by pressure ulcers, pressure ulcer surgeries, and pressure ulcer history (recurrent vs nonrecurrent). Results: 69% failed to report recurrent pressure ulcers, whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year (18% could not be classified). Logistic regression identified several general protective behaviors for recurrent pressure ulcers (eg, lifestyle, exercise, diet), none of which included those generally recommended during inpatient rehabilitation to prevent pressure ulcers (eg, skin checks, weight shifts). Fewer risk behaviors were associated with pressure ulcer history, although several proxy variables were related to pressure ulcer history. Conclusions: Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period of time (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A general healthy lifestyle appears to be strongly associated with an absence of recurrent pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated.     

Pressure ulcers in veterans with spinal cord injury: a retrospective study

Pressure ulcers are a major complication of spinal cord injury (SCI) and have a significant effect on general health and quality of life. The objectives of this retrospective chart review were to determine prevalence, duration, and severity of pressure ulcers in veterans with SCI and to identify predictors of (1) outcome in terms of healing without surgery, not healing, or referral for surgery; (2) number of visits veterans made to the SCI outpatient clinic or received from home care services for pressure ulcer treatment; and (3) number of hospital admissions and days hospitalized for pressure ulcer treatment. From a sampling frame of 553 veterans on the Houston Veterans Affairs Medical Center SCI roster, 215 (39%) were reported to have visited the clinic or received home care for pressure ulcers (ICD-9 code 707.0 = decubitus, any site) during the 3 years studied (1997, 1998, and 1999). From this sample, 102 veterans met the inclusion criteria for further analyses, 56% of whom had paraplegia. The duration of ulcers varied greatly from 1 week to the entire 3-year time-frame. Overall, Stage IV pressure ulcers were the most prevalent as the worst ulcer documented. Number and severity of ulcers predicted outcome and healthcare utilization. This study illustrates the magnitude of the pressure ulcer problem among veterans with SCI living in the community. Reducing the prevalence of pressure ulcers among veterans with SCI will have a significant impact on the Department of Veterans Affairs' financial and social resources. Innovative approaches are needed to reduce pressure ulcer risk in veterans with SCI.     

Spinal cord injury and pressure ulcers

The SCI person is at high risk for pressure ulcers; thus, pressure ulcer prevention is a critical component of care. Guidelines exist to promote evidenced-based practice for the prevention and treatment of pressure ulcers in the SCI. There is a discrepancy between what persons with SCI know about pressure ulcer prevention and what they are doing to reduce their risk of developing this serious complication. Objective data demonstrate that adherence to a skin care regimen contributes to the prevention of pressure ulcers. Knowledge about pressure ulcer prevention and treatment must be appropriately focused for the patient, family, and the health care team and must be reinforced over time.     

Spinal cord injury in Italy: A multicenter retrospective study

OBJECTIVE: To investigate certain factors influencing the length of stay (LOS) in a rehabilitation center, the incidence of pressure ulcers, and the neurologic improvement of patients with traumatic (T/SCI) and nontraumatic spinal cord injury (NT/SCI). DESIGN: A multicenter retrospective study of patients with SCI admitted to rehabilitation centers between 1 January 1989 and 31 December 1994 (only first admissions). SETTING: Seven Italian rehabilitation centers. PATIENTS: A total of 859 consecutively admitted adult patients with SCI. INTERVENTION: Examined medical records of patients admitted to rehabilitation centers. MAIN OUTCOME MEASURES: Pressure ulcers on admission as an indicator of nursing care in acute phase, LOS in rehabilitation centers, and neurologic improvement on discharge (using the Frankel classification system). Other measures included level of lesion, associated lesions (if T/SCI), surgical stabilization (if T/SCI), and time from the event to admission to a rehabilitation center. RESULTS: In all cases, the time from event to admission to a rehabilitation center exceeded 30 days (average +/- standard deviation: T/SCI, 54.6 +/- 43.7d; NT/SCI, 166.9 +/- 574d); pressure ulcers on admission were present in 34.1% of T/SCI and 17.1% of NT/SCI patients. The average LOS in a rehabilitation center was 143.1 +/- 89.1 days for T/SCI and 91.7 +/- 78.9 days for NT/SCI; Frankel grades improved by 1 or more in 34.4% of T/SCI and 34.1% of NT/SCI patients. The presence of pressure ulcers on admission, rehabilitation LOS, and neurologic improvement on discharge correlated highly with severe neurologic damage on admission in both T/SCI and NT/SCI patients as well as with management of the patient immediately before admission to a rehabilitation center, mainly in NT/SCI patients. CONCLUSIONS: Severe neurologic damage is the major determining factor in predicting neurologic recovery. Pressure ulcer prevention is statistically associated with neurologic improvement and the shortening of rehabilitation LOS. Patient management immediately before admission to rehabilitation has a statistical correlation with neurologic improvement in all patients studied and on both rehabilitation LOS and incidence of pressure ulcers in the NT/SCI patients.     

Incidence of pressure ulcers in a neurologic intensive care unit

OBJECTIVES: To determine the risk factors for pressure ulceration in an intensive care setting, to evaluate the Braden scale as a predictor of pressure ulcer risk in critically ill patients, and to determine whether pressure ulcers are likely to occur early in the hospital stay. DESIGN: Cohort study of patients with no preexisting ulcers with a 3-month enrollment period. SETTING: The neurologic intensive care unit and the neurologic intermediate unit at a primary care/referral hospital with a level I trauma center. PATIENTS: A total of 186 patients entered the study. INTERVENTION: Within 12 hrs of admittance, initial assessment, photographs, and Braden score were completed. Patients were re-examined every 4 days or at discharge from the unit, whichever came first. MAIN OUTCOME MEASURES: Determining risk factors for pressure ulcers, performing detailed statistical analyses, and testing the usefulness of the Braden score as a predictor of pressure ulcer risk. RESULTS: Twenty-three of 186 patients developed at least one pressure ulcer (incidence = 12.4%) after an average stay of 6.4 days. The Braden scale, which measures six characteristics of skin condition and patient status, proved to be a primary predictor of ulcer development. No ulcers developed in the 69 patients whose Braden score was 16 or higher. The likelihood of developing a pressure sore was predicted mathematically from the Braden score. However, being underweight was a significant and distinct factor in pressure ulcer development. CONCLUSIONS: Pressure ulcers may develop within the first week of hospitalization in the intensive care unit. Patients at risk have Braden scores of < or = 16 and are more likely to be underweight. These results suggest that aggressive preventive care should be focused on those patients with Braden scores of < or = 13 and/or a low body mass index at admission.     

重症监护室患者非骨隆突部位压疮原因分析及对策

目的：分析重症患者非骨隆突部位压疮的原因并提出相应护理对策.方法：收集从2011年12月～2012年12月我医院重症监护室收治的40例非骨隆突部位压疮患者的临床资料并进行回顾性分析,同时研究防治非骨突部位压疮的主要对策.结果：重症监护室患者头面部、上肢、腰背臀部是非骨突部位发生压疮的主要部位.结论：分析重症监护患者非骨隆突部位压疮发生的原因,并进行危险因素评估,采取针对性的护理措施利于降低重症患者非骨突部位压疮的发生率.     

An exploratory study of pressure ulcers after spinal cord injury: relationship to protective behaviors and risk factors

OBJECTIVES: To identify protective behaviors and risk factors associated with the development of pressure ulcers (PUs) after spinal cord injury (SCI). DESIGN: A cross-sectional study to evaluate the relationship between protective behaviors and risk factors and 3 PU outcomes: a current PU, PUs within the past year, and ever hospitalized for a PU. Logistic regression was then used to identify the variables most strongly associated with PU outcomes. SETTING: Data were collected by case managers employed by the Arkansas Spinal Cord Commission, an agency that provides services to persons with SCI. PARTICIPANTS: A total of 650 of 991 eligible individuals with SCI from a statewide population-based SCI registry participated. All ambulatory participants were eliminated, leaving 560 patients. Average age of the respondents was 27.2 years at injury (median age, 25yr) and 43.6 years at the time of the survey (median age, 42yr). MAIN OUTCOME MEASURES: A 200-item interview was developed to measure a broad range of outcomes associated with SCI (including secondary conditions such as PUs), as well as risk and protective behaviors related to these outcomes. RESULTS: Several characteristics and behaviors were related to PU outcomes. Being underweight (odds ratio [OR] = 2.18), having used medications to treat pain (OR = 1.33) or spasticity (OR = 1.31), having smoked at least 100 cigarettes over a lifetime (OR = 1.31), and being a current smoker (OR = 1.21) were associated with having a PU in the past year. Having completed a college degree (OR = 0.23), being married (OR = 0.49), and being currently employed (OR = 0.54) were associated with a lower risk of having a PU in the past year. Being underweight (OR = 1.94), having a history of incarceration (OR = 1.78), having attempted suicide (OR = 1.71), and reporting alcohol or drug treatment (OR = 1.65) were associated with having been hospitalized for a PU since injury. This study was unable to evaluate the efficacy of traditional health maintenance or protective behaviors for PUs, such as weight shifts or skin checks. CONCLUSIONS: PUs are least likely to occur among individuals who maintain normal weight, return to a work and family role, and who do not have a history of tobacco use, suicidal behaviors, or self-reported incarcerations, or alcohol or drug abuse. Additional research is needed to identify better the risk factors for the occurrence of PUs.     

The prevalence of pressure ulcers in four paediatric institutions

Aim and objective. Pressure ulcers are a common nursing care issue in hospitals. They are associated with psychological and physical suffering, an increased morbidity and mortality rate and higher overall health care costs. The aim of the current study is to describe the frequency of pressure ulcers in a paediatric care setting and to identify the population at risk, as well as to assess the factors predisposing to the development of pressure ulcers. Design. A point prevalence study. Methods. The study was conducted in four paediatric hospitals in the German‐speaking part of Switzerland and included children from the age of 0–18 years. The method of data collection was a direct systematic inspection and assessment of the skin, taking into account the clinical condition of the patient for risk assessment. A valid risk assessment and data collection instrument was used and, each patient was assessed by a previously instructed rater pair. Results. Of all possible patients, 81% (n = 155) were included. An overall pressure ulcer prevalence of 27·7% (including grade 1) was registered. Thirty‐six patients (84%) had grade 1 ulcers, including many caused by external medical devices. Sixty‐five per cent (n = 100) of all patients were considered at risk (Braden score ≤ 20) of developing a pressure ulcer. Thirty‐five per cent of patients in the risk group were afflicted with one or more pressure ulcers. Conclusions. The prevalence of pressure ulcers in paediatric patients is greater then previously appreciated and the problem requires further exploration. The high percentage of grade 1 pressure ulcers caused by medical devices requires nursing interventions to prevent lesions for these patients. Relevance to clinical practice. The high prevalence rate in paediatric patients is disconcerting and requires further exploration in terms of interventions needed to improve outcomes for this patient group.     

Validity of the Waterlow scale for pressure ulcer risk assessment in the intensive care unit: a prospective analysis of 698 patients

Critically ill patients are at a particular risk for developing pressure ulcers. Yet until now, no sufficiently specific, validated pressure ulcer risk assessment instruments exist for critically ill patients. In a prospective study of 698 patients of medical intensive care unit (ICU), we therefore analyzed if the Waterlow scale is suitable for pressure ulcer risk assessment in the ICU. Only patients with no pressure ulcer on admission to the ICU were included. The Waterlow scale was used to assess pressure ulcer risk on admission to the ICU, and the number of points on the scale were analyzed with regard to pressure ulcers development in the course of the ICU stay (121 patients). Our results show that adequate pressure ulcer risk assessment on admission to the ICU is not possible with the Waterlow scale. Sensitivity and specificity reached their maximal values of 64.6% and 48.8%, respectively, at a comparably high cut-off of 30 points on the Waterlow scale (positive and negative likelihood ratio being 1.26 and 0.73, respectively). The area under the curve (AUC) was 0.59 in the receiver-operator-characteristic curve. Adding intensive care related parameters to the scale yielded some degree of improvement (AUC 0.69), but the development of ICU specific pressure ulcer risk scales still seems to be necessary to allow reliable pressure ulcer risk assessment in the ICU.     

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.     

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.