Evaluation of patient outcomes: pressure ulcer prevention mattresses

This article reports the findings of a small evaluation audit which compares the Dyna-Form Mercury Advance Mattress to that of the Softform Premier Active Mattress (a foam mattress with dynamic underlay). A small group of patients with similar co-morbidities who were an emergency admission were recruited to an evaluation audit. Their median age and Waterlow score indicated that these patients were at high risk of pressure ulcer development. All patients were given the same nursing care on the two mattresses and all were moved, handled and repositioned 2-4 hourly. Of the patients nursed on the Dyna-Form Mercury Advance mattress, three did not develop pressure ulcers. The two who already had pressure ulcers when they were recruited appeared to have healed within four days. Of the patients nursed on the Softform Premier Active mattress, three patients did not develop ulcers and two did. Although the sample size was small, the comprehensive assessment gave interesting results, particularly on the Dyna-Form Mercury Advance. A larger study may be of benefit to demonstrate efficacy of these products further.     

Efficacy and cost-effectiveness of the Thermo contour mattress

Use of air mattresses in reduction of pressure sore incidence is an important part of quality patient care. However, there will never be enough air mattresses to match the demand as increased education and an increase in the general provision of air mattresses can lead to an unrealistic expectation of obtaining air mattresses when required for patients. This raises the demand for air mattresses and increases costs within hospital trusts. This study examined a way to redress the balance through use of an alternative, cost-effective type of mattress (thermoelastic polymer) in the prevention of pressure sores. Prime consideration was given to the comfort of the patient. The claims of the manufacturers, Barrington Healthcare, that 'patients with Waterlow scores of 23 can be nursed safely on this product' were explored as part of the study. A total of 407 patients took part over a 6-month period. Twenty-four Thermo contour mattresses were loaned to one ward for the study and patients were allocated to the mattress through admission to the experimental ward. Patients were then split into two groups on two wards. Group B were allocated to a Thermo contour mattress and group A were nursed on air mattresses and foam mattresses generally used throughout the trust. Results showed that more patients were comfortable on the Thermo contour mattresses than on all other mattresses. Patients with Waterlow scores under 25 did not develop pressure sores on the Thermo contour mattress. However, the sample of patients with a Waterlow score of between 20 and 25 was small and therefore further research is required.     

ProfiCare: an alternating pressure-relieving mattress

Risk assessment tools should only act as a guide to patient status rather than definitive diagnosis. Emphasis must be placed on not using the Waterlow score in isolation but in conjunction with clinical judgement. We must therefore attempt to minimize opportunities for disagreement over pressure ulcer risk scores through the selection of appropriate support surfaces based on a thorough consideration of costs of pressure ulcers for the patients, institutions and healthcare professionals. This product focus advocates that ProfiCare replacement mattresses are an option as they are designed for use on a hospital bed frame and provide alternating and static patient support surfaces.     

Pressure-relieving equipment: promoting its correct use amongst nurses via differing modes of educational delivery

Aims and objectives. To examine the impact of written and verbal education on bed‐making practices, in an attempt to reduce the prevalence of pressure ulcers. Background. The Department of Health has set targets for a 5% reduction per annum in the incidence of pressure ulcers. Electric profiling beds with a visco‐elastic polymer mattress are a new innovation in pressure ulcer prevention; however, mattress efficacy is reduced by tightly tucking sheets around the mattress. Design. A prospective randomized pre/post‐test experimental design. Methods. Ward managers at a teaching hospital were approached to participate in the study. Two researchers independently examined the tightness of the sheets around the mattresses. Wards were randomized to one of two groups. Groups A and B received written education. In addition, group B received verbal education on alternate days for one week. Beds were re‐examined one month later. One researcher was blinded to the educational delivery received by the wards. Results. Twelve wards agreed to participate in the study and 245 beds were examined. Before education, 113 beds (46%) had sheets tucked correctly around the mattresses. Following education, this increased to 215 beds (87.8%) (χ² = 68.03, P < 0.001). There was no significant difference in the number of correctly made beds between the two different education groups: 100 (87.72%) beds correctly made in group A vs. 115 (87.79%) beds in group B (χ² = 0, P = 0.987). Conclusions. Clear, concise written instruction improved practice but verbal education was not additionally beneficial. Relevance to clinical practice. Nurses are receptive to clear, concise written evidence regarding pressure ulcer prevention and incorporate this into clinical practice.     

Collecting pressure ulcer prevention and management outcomes: 1

This article, the first of two parts, presents the argument that a combination of efficacy and effectiveness is required to assess fully the impact of interventions such as pressure-redistributing beds and mattresses. The methodology adopted within a multinational, multicentre, prospective, non-randomized cohort study, designed to record the occurrence and characteristics of patients vulnerable to, or with, established pressure ulcers, is described. General demographic data and the characteristics of the pressure ulcers experienced by the 2507 UK subjects recruited to the study across four UK hospitals between July 1996 and May 1998 are presented, with pressure ulcers affecting 218 subjects of whom 100 presented with ulcers on admission to hospital. Fourteen subjects developed severe ulcers, while a further 24 were admitted with full-thickness pressure ulcers. The second part of this article will report further details of the characteristics of the UK sample. Future articles will consider the subjects examined in greater detail and will also discuss the combination of this dataset with similar data collected in the USA.     

An audit of pressure ulcer incidence in a palliative care setting

This article reports a continuous audit of pressure ulcer incidence within a specialist palliative care unit over 2 years. Details of every patient admission were considered (542 patients). Of these, 26.1% were admitted with pressure ulcers while 12.0% developed pressure damage during their stay. The retrospective audit looked at the ulcers developing in the unit and found these patients were older, stayed 12 days longer and more of them died than the average for all patients admitted to the unit. In total, 95.3% were accurately assessed at 'high' or 'very high' risk using the Waterlow (1985) Pressure Sore Risk Assessment Tool and 89.2% of ulcers were Grade 1 or 2 measured using the Stirling Pressure Sore Severity Scale (Reid and Morrison, 1994). Of all developing ulcers, 78.4% were sacral and the position of the tumour, as well as comfort and positioning difficulties were considered most often responsible. Despite this knowledge and many 'improvements' introduced, the incidence did not improve with superficial ulcers often developing in the last days of life.     

Time in bed after electrophysiological procedures (TIBS IV): a pilot study.

BACKGROUND: Electrophysiological studies of the heart became commonplace in the past decade. Like cardiac catheterizations, electrophysiological studies are often considered "same day" procedures; patients are admitted in the morning, undergo the procedure, recover for several hours while confined to bed, and then are discharged from the hospital. The requisite time in bed varies widely between institutions where electrophysiological studies are performed. Little has been published about the optimal time that patients should remain in bed. OBJECTIVE: To determine if the requisite time in bed could be safely reduced by 2 hours for patients recovering from electrophysiological studies done via a femoral venous approach. METHODS: An experimental-control group design was used. A total of 68 patients were randomized to 2 hours (n = 31) or 4 hours (n = 37) of bed rest. Groups were comparable in age and sex. Both groups were observed for 5 hours after the procedure. RESULTS: The incidence of bleeding did not differ significantly between the experimental and control groups. Bleeding occurred in only 1 patient. CONCLUSIONS: The required 4 hours of bed rest after an electrophysiological study done via a femoral vein approach can safely be reduced to 2 hours. Early ambulation has implications for decreasing the cost of nursing care after the procedure and decreasing length of hospital stay, thus optimizing utilization of beds for recovery.     

An exploration of the occurrence of pressure ulcers in a British spinal injuries unit

Spinal cord injury (SCI) is associated with increased risk of pressure ulcers, but there are few published data about this in the United Kingdom (UK). This article represents a quantitative exploration of the occurrence of pressure ulcers in a UK spinal injuries unit (SIU). The technique used is a retrospective review of records: details of 144 completed first admissions for SCI between 1998 and 2000 were entered on to a database (SPSS) for analysis. Thirty-two per cent of patients already had pressure ulcers on admission to the SIU, while a total of 56% experienced an ulcer at some stage between injury and discharge from the SIU. Four pressure ulcer risk assessment scales were used (Waterlow, Braden, Norton and SCIPUS-A). These appeared to have moderate predictive power in this population. Pressure ulcers were found to be associated with increased length of hospital stay, density of lesion, surgical stabilization of neck injury before transfer to the SIU, tracheostomy on admission to the SIU and delayed transfer to the SIU after injury. Implications for practice are discussed.     

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.     

Changing pressure-redistributing mattress stocks: costs and outcomes

There remains considerable confusion regarding the selection of appropriate pressure-redistributing support surfaces, although it is accepted that use of low-pressure foam mattresses is likely to reduce the incidence of pressure ulcers compared with standard hospital mattresses. In this study, a 650- hospital replaced its mattress stock with low-pressure foam mattresses with over pounds sterling 100 000 cost savings in the first year after implementation. Incidence and prevalence data were recorded but given the challenges of interpreting apparent trends in the data (due to the lack of robust data collection methodologies and no case-mix adjustment) these data were not included.     

Risks related to patient bed safety

There is heightened public awareness of the inherent risks of hospitalization. The hospital bed itself, however, is often not where jeopardy is expected. This article examines 3 chief contributors to hazards associated with hospital bed systems: fire, entrapment, and pressure ulcers. Strategies to assess beds for safety risks are discussed.     

The surveillance system of decubital lesions of the University Polyclinic in Udine: results of an incidence study

A retrospective study of the incidence of pressure sores was one of the principal component of the ad hoc program of surveillance, prevention and treatment of pressure sores started in 1996 at University Hospital of Udine. Data were collected from the nursing records of patients defined at risk according to the Waterlow scale and admitted during 1998-99. Aims of the study were to quantify the number of patients who developed a pressure sore while in hospital and their risk level; stage of the lesions; to qualify the main risk factors and the management strategies adopted (i.e. mattresses, medications). Overall, 151 subjects (20.7% of those recruited) developed a pressure sore the greatest majority (96%) were classified as transient and reactive redness or superficial sore, while 14 patients (4%) developed a severe sore. For 50.4% of the lesions a regression to a lower risk level or healing were documented.     

Evaluation of an electric bed frame and pressure-reducing mattresses

Pressure ulcers remain a challenge to all healthcare professionals. With the trend towards caring for ill patients in the community there is a need to ensure that equipment used to prevent pressure ulcers in these patients is effective. It is not always appropriate to simply use equipment designed for hospital. This article describes the evaluation of an electric bed frame and three mattresses specifically designed for patients in the community, in either their own homes or nursing home/residential care. The location of this research can reduce the number of participants recruited. In order to compensate for this, three different methods of evaluation were employed - clinical, laboratory and anecdotal - which have produced results relevant to both purchasers and users of the system tested.     

Kinetic therapy reduces complications and shortens hospital stay in patients with cardiogenic shock - a retrospective analysis.

BACKGROUND: Kinetic therapy (KT) has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients are inconclusive, and kinetic therapy has not been tested in patients with cardiogenic shock. OBJECTIVE: The present analysis compares KT with standard care in patients with cardiogenic shock. METHODS: A retrospective analysis of 133 patients with cardiogenic shock admitted to 1 academic heart center was performed. Patients with standard care (SC, turning every 2 h by the staff) were compared with kinetic therapy (KT, using oscillating air-flotation beds). MEASUREMENTS AND MAIN RESULTS: 68 patients with KT were compared with 65 patients with SC. Length of ventilator therapy was 11 days in KT and 18 days in SC (p=0.048). The mortality was comparable in both groups. Pneumonia occurred in 14 patients in KT and 39 patients in SC (p<0.001); pressure ulcers were reduced by 50% (p<0.001). Length of ICU stay (21 days in SC and 13 days in KT, p=0.009) and length of hospital stay were reduced in the patients treated with kinetic therapy. CONCLUSION: The use of KT shortens hospital stay and reduces rates of pneumonia and pressure ulcers as compared to SC.     

Matching patient need for pressure sore prevention with the supply of pressure redistributing mattresses

The authors have conducted a series of pressure sore prevalence surveys within one health district over a 4-year period. Additional surveys of the availability and deployment of pressure redistributing (PR) bed mattresses have also been made within the same district. The prevalence of pressure sores increased from 6.8% (1986) to 14.2% (1989) while the available stocks of PR mattresses increased from 69 (1987) to 186 (1989). Our results appear to question the common assumption that successful pressure sore prevention can be achieved through expanding the stocks of PR mattresses. Five possible reasons why the increase in mattress provision was matched with an increased prevalence of pressure sores are forwarded. The use of measures of prevalence rather than incidence rates to monitor the effects of clinical initiatives is discussed.     

Factors associated to pressure ulcers in patients at adult Intensive Care Units

The objective of this a cross-sectional analytical study was to estimate the occurrence of pressure ulcers and their associated factors in adult ICUs in the city of Belo Horizonte, Brazil. The sample consisted of 142 patients aged 18 or older, admitted before midnight of the day prior to data collection, from a total of 316 beds distributed in 22 ICUs. Presence of at least one pressure ulcer per patient was 35.2% (CI 95% = 27.4-47.7). Of the 99 ulcers identified, the ones in the sacral region were most frequent (36.0%), followed by those in the calcaneus (22.0%). We observed that the presence of sepsis (OR = 6.04, CI 95% = 1.09-33.53), period of stay > or = 10 days (OR = 7.61, CI 95% = 2.92-19.82) and being high risk and very high-risk in the Braden scale (OR = 4.96, CI 95% = 1.50-16.50) were independent factors significantly associated with the presence of pressure ulcers. Results suggest that sepsis, length of stay, and having high and very high risk" in the Braden scale are factors potentially associated to the development of ulcers in bedridden patients.     

A comparison of mite populations in mattress dust from hospital and from private houses in Cardiff, Wales.

Fifty mattress dust samples from private houses were examined--all were mite infested. Dermatophagoides pteronyssinus occurred in all samples and accounted for 81% of all mites. In thirty-two paired samples the total mite population of bedroom floor dust was only 10% of that found in the corresponding mattress dust. D. pteronyssinus was the dominant species in both and the population of this mite amounted to 7-5% of that found in the mattress dust. An analysis of mattress dust from 100 hospital beds showed that ninety-four mattresses were mite free; the other six contained only seven mites, all D. pteronyssinus. It is suggested that frequent changing and washing of bed linen and brushing and cleaning of mattresses were the main factors in preventing mite infestation in the Cardiff hospitals.     

Providing correct pressure-relieving devices for optimum outcome

Pressure redistributing (PR) support surfaces are positioned by manufacturers against different levels of patient vulnerability to developing pressure ulcers. However, there is no agreed method through which such linkage between a patient and an appropriate support surface can be made. This lack of clarity leads to new devices being positioned in a manner not representative of their eventual use in clinical practice. Using a data hierarchy approach, three strands of evidence (interface pressure, a pilot national survey and a randomized controlled trial) are presented to illustrate, and support, the repositioning of the Viaclin dynamic mattress overlay (formerly the Pegasus Overture) from use with medium-risk patients to use with higher-risk patients. The need for amendment is seen most strikingly in the two clinical studies featured in this article, during which 87% of all patients nursed on the Viaclin dynamic mattress overlay were at high- to very high-risk of developing ulcers.