A study to evaluate factors for inclusion in a new self-assessed risk indicator for persons who use a wheelchair for mobility

A preliminary analysis of a 2-year prospective study of the health, degree of physical disability and skin integrity of 160 permanently seated persons is presented in this paper. The study was undertaken to inform the development of a self-managed risk assessment tool for the prevention of pressure ulcers in permanently seated individuals. The results of this study offer further insight into the challenges of pressure ulcer prevention and the role of education and self management in achieving this.     

Seated buttocks anatomy and its impact on biomechanical risk

AimThe objective of this study was to describe the amount, types, and shapes of tissue present in the buttocks during sitting (i.e., seated buttocks soft tissue anatomy), and the impact of seated buttocks soft tissue anatomy on biomechanical risk.Materials and methodsThe buttocks of 35 people, including 29 full-time wheelchair users with and without a history of pelvic pressure ulcers were scanned sitting upright on 3” of flat HR45 foam in a FONAR Upright MRI. Multi-planar scans were analyzed to calculate bulk tissue thickness, tissue composition, gluteus maximus coverage at the ischium, the contour of the skin, and pelvic tilt.ResultsBulk tissue thickness varied from 5.6 to 32.1 mm, was composed mostly of adipose tissue, and was greatest in the able-bodied cohort. Skin contours varied significantly across status group, with wheelchair users with a history of pressure ulcers having tissue with a peaked contour with a radius of curvature of 65.9 mm that wrapped more closely to the ischium (thickness at the apex = 8.2 mm) as compared to wheelchair users with no pressure ulcer history (radius of curvature = 91.5 mm and apex thickness = 14.5 mm). Finally, the majority of participants presented with little to no gluteus coverage over their ischial tuberosity, regardless of status group.ConclusionsThis study provides quantitative evidence that Biomechanical Risk, or the intrinsic characteristic of an individual's soft tissues to deform in response to extrinsic applied forces, is greater in individuals at greater risk for pressure ulcers.     

Developing the tissue viability seating guidelines

BackgroundCosts for the prevention and management of pressure ulcers have increased significantly with limited published advice from health and social care organisations on seating and preventing pressure ulcers. At the request of the UK Tissue Viability Society the aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time.Methods and findingsThe evidence base informing the guidelines was obtained by applying a triangulation of methods: a literature review, listening event and stakeholder group consultation. The purpose was to engage users and carers, academics, clinicians, inspectorate and charities, with an interest in seating, positioning and pressure management to: gather views, feedback, stories, and evidence of the current practices in the field to create a greater awareness of the issue.ConclusionThe new guidelines are inclusive of all people with short and long-term mobility issues to include all population groups. The document includes evidence on where pressure ulcers develop when seated, risk factors, best possible seated position and what seat adjustments are required, the ideal seating assessment, interventions, self-help suggestions and key seating outcomes. The updated TVS CPGs have been informed by the best available evidence, the insights and wisdom of experts, stakeholders and people who spend extended periods of time sitting.     

Pressure relief behaviour and the prevention of pressure ulcers in wheelchair users in the community

This study aims to provide an insight into wheelchair users' preventative health behaviours with respect to pressure-relief behaviour, perceived risk and attribution of responsibility for preventative health measures. Wheelchair users who are dependent upon a wheelchair for their indoor and outdoor mobility have a long-term risk of developing a pressure ulcer. In an attempt to lessen the risk they need to perform pressure-relieving movements frequently. The Department of Health currently advises wheelchair users to perform a pressure-relieving movement every 15 minutes. Many wheelchair users responding to this large scale survey reported that although they were physically capable of performing pressure-relieving movements without help, they either did not do them or did not adhere to current advice. Of those who responded, 20.8% moved only once an hour and a further 54.7% moved less often than once an hour. This study is part of a wider study investigating the preventative health behaviours of wheelchair users.     

Skin blood flow dynamics and its role in pressure ulcers

Pressure ulcers are a significant healthcare problem affecting the quality of life in wheelchair bounded or bed-ridden people and are a major cost to the healthcare system. Various assessment tools such as the Braden scale have been developed to quantify the risk level of pressure ulcers. These tools have provided an initial guideline on preventing pressure ulcers while additional assessments are needed to improve the outcomes of pressure ulcer prevention. Skin blood flow function that determines the ability of the skin in response to ischemic stress has been proposed to be a good indicator for identifying people at risk of pressure ulcers. Wavelet spectral and nonlinear complexity analyses have been performed to investigate the influences of the metabolic, neurogenic and myogenic activities on microvascular regulation in people with various pathological conditions. These findings have contributed to the understanding of the role of ischemia and viability on the development of pressure ulcers. The purpose of the present review is to provide an introduction of the basic concepts and approaches for the analysis of skin blood flow oscillations, and present an overview of the research results obtained so far. We hope this information may contribute to the development of better clinical guidelines for the prevention of pressure ulcers.     

The impact of hoist sling fabrics on interface pressure whilst sitting in healthy volunteers and wheelchair users: A comparative study

Aim of the studyTo evaluate the effect of three sling fabrics on gluteal interface pressure whilst sitting in a population of wheelchair users and to compare these to data previously collected in a pilot study with a healthy population.Materials and methodsA repeated measures experimental design was used with 32 adult wheelchair users (15 women, 17 men). Healthy population pilot study consisted of 61 participants (51 women, 10 men) recruited from staff and students at The University of Salford.MethodsGluteal pressures at six pressure zones were recorded using the X-sensor PX100 pressure sensor at 30 s intervals for 10 min. Data were collected in 4 conditions with participants seated in a standardised chair, followed by the chair with slings made of three different fabrics.ResultsThe spacer fabric reduced the mean gluteal pressure more effectively than slipfit and polyester (p = 0.014 and p = 0.01 respectively, 95%CI) and reduced peak pressure at the left ischial tuberosity and coccyx when compared to the slipfit (p = 0.003 and p = 0.005) with the wheelchair users. When comparing data with the pilot study, the mean gluteal pressure and peak pressures at the ischial tuberosities and coccyx were significantly higher in the wheelchair user group (p < 0.005).ConclusionThe fabric identified as the most effective in reducing mean and peak pressures in both groups was the spacer fabric, suggesting that a spacer fabric sling is more likely to reduce the risk of pressure ulcer development.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.     

Seating and pressure ulcers: Clinical practice guideline

Pressure ulcers (bedsores) often develop following prolonged sitting especially where people are immobile or are unable to feel discomfort due to injury or disease. This guideline provides health professionals with specific recommendations intended to minimise any risk of developing pressure ulcers when their clients are seated. The guideline covers sitting when people are acutely ill in hospital and, more commonly, where people have a long-term need for prolonged sitting for example after spinal injury. Particular focus is placed upon the need to make sure the physical size and shape of the seat is appropriate for the seated individual. Guidance is provided upon areas where seated individuals require information to help them minimise pressure ulcer development. The advantages and disadvantages of different cushion materials are described.     

Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program

OBJECTIVE: To provide health care organizations with strategies for decreasing the prevalence of hospital-acquired pressure ulcers. DESIGN: Hospital-acquired pressure ulcer prevalence was measured every 6 months for 4.5 years while multiple strategies were implemented. SETTING: The study took place in a not-for-profit, 548-bed, 2-hospital system in Southwest Florida. PATIENTS: All adult patients with the exception of those admitted for obstetric or mental health care. INTERVENTIONS: An assortment of interventions were implemented, including electronic medical records, risk assessment tied to automatic consults, pressure relief measures including new equipment and personnel augmentation, and an interdisciplinary team to decide on protocols. MAIN RESULTS: Hospital-acquired prevalence rate for all pressure ulcers was reduced by 81%. The rate for heel ulcers alone was reduced by 90%. CONCLUSION: A pressure ulcer prevention program has been developed, which has shown a trend toward improved patient outcomes with a resultant cost savings.     

The prevalence,management, equipment provision and outcome for patients with pressure ulceration identified in a wound care survey within one English health care district

The prevalence of pressure ulceration within the population receiving health care in Bradford, UK was 0.74 people with a pressure ulcer per 1000 population (95% CI 0.6–0.8). This prevalence includes a number of tertiary referrals and if these are removed the prevalence falls to 0.71 people with a pressure ulcer per 1000 population. Of the pressure ulcers encountered 195 (53.7%) were classed as grade 2 pressure ulcers with 80 grade 3 wounds and 40 grade 4 pressure ulcers. Forty-eight pressure ulcers were identified as grade 1 wounds but the accuracy of this classification may be in doubt given that 24 apparent grade 1 pressure ulcers were reported to have visible wound beds with common reports of slough and granulation tissue. Severe pressure ulcers differed from less severe partial thickness wounds – grade 3 and 4 pressure ulcers tended to be larger, of longer duration, with greater coverage of the wound bed with necrotic tissue and less granulation and epithelial tissue. Wound exudate was heavier where people presented with severe pressure ulcers while there was a greater probability of wound infection (37.5% of grade 4 pressure ulcers were infected). Given these challenges it was perhaps unsurprising that people with severe pressure ulcers were more likely to have been risk assessed, to have had a critical incident form completed (although only 35% of grade 4 pressure ulcers were identified as having been reported on a critical incident form), to be provided with a powered PR mattress in bed and to be dressed with an antimicrobial dressing. The time to treat each severe pressure ulcer tended to be longer than was the treatment times for less severe wounds. Only 40 people with pressure ulcers (11%) as their most serious wound were located in hospital, suggesting that current pressure ulcer epidemiology and costs may be understated given their reliance on previous hospital based surveys of pressure ulcers. Another potential confounder of pressure ulcer epidemiological studies may be the number of nursing home beds in the surveyed population. On breaking down the Bradford audit data by postcode the pressure ulcer prevalence ranged between 0.13 and 1.39 people with a pressure ulcer per 1000 population with the higher prevalence proportions found in postcodes with large numbers of nursing home beds. It would appear to be prudent to record the number of nursing home beds within community based populations where pressure ulcers (and potentially other wounds) are being recorded.     

A new instrument for predicting pressure ulcer risk in an intensive care unit

The purpose of this study was to assess the utility of two instruments (the Braden scale and a multi-pad pressure evaluator) for predicting pressure ulcer development. A prospective cohort design was used and 105 intensive care unit patients participated in this study. The result was a 33% incidence of pressure ulcers. Both the Braden score and the multi-pad pressure evaluator instruments gave significant differences between patients who did and did not develop pressure ulcers. The predictive validity of these tools was calculated. The results indicated that the multi-pad pressure evaluator provided the best balance between sensitivity and specificity. We suggest that the multi-pad pressure evaluator may be better suited for assessing the risk of pressure ulcers in intensive care units.     

The trend of pressure ulcer prevalence rates in German hospitals: Results of seven cross-sectional studies

Pressure ulcer prevalence rates provide useful information about the magnitude of this health problem. Only limited information on pressure ulcers in Germany was available before 2001. The purpose of this study was to compare results of seven pressure ulcer prevalence surveys which were conducted annually between 2001 and 2007 and to explore whether pressure ulcer prevalence rates decreased. The second aim was to evaluate if the measured prevalence rates of our sample could be generalised for all German hospitals.Results of seven point pressure ulcer prevalence studies conducted in 225 German hospitals were analysed. Chi-square tests, chi-square trend tests and one-way ANOVA to assess differences and trends across the years were applied. The sample was stratified according to pressure ulcer risk and speciality. Finally, study samples were compared with the potential population.In total data of 40,247 hospital patients were analysed. The overall pressure ulcer prevalence rate in German hospitals was 10.2%. Patient samples of each year were comparable regarding gender, age and pressure ulcer risk. Pressure ulcer prevalence rates decreased from 13.9% (year 2001) to 7.3% (year 2007) (p < 0.001). When excluding non-blanchable erythema prevalence rates decreased from 6.4% (year 2001) to 3.9% (year 2007) (p = 0.015). An explicit decrease of prevalence rates was observed on geriatric wards. Prevalence rates on neurological and intensive care units remained stable. With some limitations our study results are representative for all hospitals within Germany.It is highly probable that the decrease of prevalence rates was due to an increased awareness of the pressure ulcer problem in Germany and subsequent efforts to improve pressure ulcer prevention and treatment. The quality of clinical practice regarding pressure ulcer prevention and treatment has improved. However, pressure ulcers are still relevant and require attention. In 2007, one out of 10 hospital patients who were at pressure ulcer risk had at least one pressure related skin damage.     

Pediatric skin care: guidelines for assessment, prevention, and treatment

The review of the literature suggests the pediatric population is at risk for skin breakdown and therefore pressure ulcer development. The literature reveals limited information on pediatric skin care issues in comparison to the adult population. The prevention and treatment of pressure ulcers and maintenance of skin integrity in the pediatric population often is not a high priority, especially in the critically ill child. Research has demonstrated that children differ from adults in the anatomical sites of skin breakdown; however, treatment remains the same. It is important to have an understanding of the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. Accurate assessment, documentation, prevention, and treatment are all key factors.     

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 prevention in black and white nursing home residents: A QI initiative of enhanced ability, incentives, and management feedback

OBJECTIVE: To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents. DESIGN: Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods. PARTICIPANTS: All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania. MAIN OUTCOME MEASURE: The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV). RESULTS: At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends. CONCLUSION: Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.     

Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units

To describe the prevalence and incidence density of hospital-acquired unavoidable pressure sores among patients aged ≥65 years admitted to acute medical units. A secondary analysis of longitudinal study data collected in 2012 and 2013 from 12 acute medical units located in 12 Italian hospitals was performed. Unavoidable pressure ulcers were defined as those that occurred in haemodynamically unstable patients, suffering from cachexia and/or terminally ill and were acquired after hospital admission. Data at patient and at pressure ulcer levels were collected on a daily basis at the bedside by trained researchers. A total of 1464 patients out of 2080 eligible (70.4%) were included. Among these, 96 patients (6.5%) hospital-acquired a pressure ulcer and, among 19 (19.7%) were judged as unavoidable. The incidence of unavoidable pressure ulcer was 8.5/¹⁰⁰ in hospital-patient days. No statistically significant differences at patient and pressure ulcers levels have emerged between those patients that acquired unavoidable and avoidable pressure sores. Although limited, evidence on unavoidable pressure ulcer is increasing. More research in the field is recommended to support clinicians, managers and policymakers in the several implications of unavoidable pressure ulcers both at the patient and at the system levels.     

Exploring repositioning movements in sitting with ‘at risk’ groups using accelerometry and interface pressure mapping technologies

BackgroundDespite high quality guidelines underpinning pressure ulcer care (NPUAP/EPUAP/PPPIA, 2014), pressure ulceration still poses a significant financial impact on health care services in treatment and staff costs as well as having a profound effect on the health and quality of life of individuals experiencing them. Repositioning is a key preventative technique recommended by occupational therapists and other health care professionals. The frequency and quality of repositioning movements performed by individuals, however, can be difficult to determine. This paper explores the use of technology in monitoring repositioning movements in sitting.ObjectiveTo explore the outputs of technologies such as interface pressure mapping systems and accelerometers in enabling the therapist to accurately monitor seated behaviour and enhance practice through targeted interventions to prevent sitting acquired pressure ulceration.MethodReviewing the findings of two recent research studies with ‘at risk’ cohorts (spinal cord injury; elderly orthopaedic), using accelerometry and seated interface pressures, this paper will highlight how useful this technology is in clinical practice to monitor weight shifts and repositioning behaviours.ResultBoth studies illustrated that the majority of individuals did not adhere to the frequency or magnitude of movements currently recommended to redistribute seating interface pressures. When repositioning was performed it was ineffective in reducing seated pressures.ConclusionIn an era of personalised medicine, technology has an important role to play in providing the service user, caregivers and healthcare staff with important biofeedback information about seated behaviours, particularly those that minimise the risk of developing sitting acquired pressure ulcers. This information can augment occupational therapists' clinical decision-making in maximising active pressure ulcer prevention.     

Pressure ulcers: a review

Pressure ulcers continue to be a major problem for the immobilized elderly person. Approximately 3% to 5% of hospitalized persons and up to 45% of those in long-term care facilities develop pressure ulcers. Etiological factors for pressure ulcers are discussed as well as other factors contributing to pressure ulcer formation.