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

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

Improving pressure ulcer prevention through education

Pressure ulcers adversely affect the quality of life of many patients and cause anxiety and distress for their families. Pressure ulcer prevention and management is an integral part of nursing practice, but despite numerous policies and guidelines, research, and improvements in equipment, the incidence and prevalence of pressure ulcers have not fallen. In this article, the author examines issues involved in promoting more effective pressure ulcer management.     

Oh my,the pressure!

The intraoperative phase of a surgical patient's hospital stay has been overlooked as a major contributor of pressure ulcers that may arise postoperatively. Pressure ulcers are defined and then the hazards, underlying knowledge, and prevention tactics are reviewed. Bed sore, decubitous ulcer, pressure sore, and pressure ulcer are different terms describing the same problem encountered by medical and surgical patients. The common denominator is pressure--sustained pressure.     

The Effectiveness of Skin Care Protocols for Pressure Ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.     

Risky business: Preventing skin breakdown in children with spina bifida

The purpose of this article is to provide an overview of skin issues in children with spina bifida. Included in the discussion below is a review of the etiology of pressure ulcers and the updated 2007 pressure ulcer definition and pressure ulcer staging system as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Pediatric risk factors for skin breakdown are presented including risk factors unique to children with spina bifida. Pediatric pressure ulcer risk assessment scales are described. The 5 Million Lives Kids' Campaign which has a focus on preventing hospital-acquired pressure ulcers in children is also reviewed along with evidence based prevention strategies. The key to preventing skin breakdown and pressure ulcers in children with spina bifida is early identification of the child's individual risk factors so that a prevention protocol can be implemented in all settings: hospital, home and the community. Options for wound management, dressing selection and pain management are included.     

The braden q+p: a pediatric perioperative pressure ulcer risk assessment and intervention tool

Pressure ulcers continue to be a personally and financially expensive complication of surgery and hospitalization. The effects of anesthesia, immobilization during surgery, and use of multiple medical devices all place the surgical patient at high risk for pressure-related skin injury. As part of a comprehensive pressure ulcer prevention initiative, nurses in the cardiac and main ORs at Children's Hospital Boston, Massachusetts, became concerned that current pressure ulcer risk assessment tools did not adequately capture the intense but short-term risk posed in the operating and procedural suites. A team, formed to investigate this matter, developed a tool to guide nursing assessment of patient risk and to plan nursing interventions to prevent pressure ulcers. Results after implementation of the Braden Q+P tool appear to show improvement in preventing pressure ulcers. Increased awareness of pressure ulcer prevention, a hospital focus on skin care, and nursing education about pressure ulcers supported this improvement.     

Inter-rater reliability of the EPUAP pressure ulcer classification system using photographs

Background. Many classification systems for grading pressure ulcers are discussed in the literature. Correct identification and classification of a pressure ulcer is important for accurate reporting of the magnitude of the problem, and for timely prevention. The reliability of pressure ulcer classification systems has rarely been tested. Aims and objectives. The purpose of this paper is to examine the inter‐rater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using pressure ulcer photographs. Design. Survey was among pressure ulcer experts. Methods. Fifty‐six photographs were presented to 44 pressure ulcer experts. The experts classified the lesions as normal skin, blanchable erythema, pressure ulcer (four grades) or incontinence lesion. Inter‐rater reliability was calculated. Results. The multirater‐Kappa for the entire group of experts was 0.80 (P < 0.001). Various groups of experts obtained comparable results. Differences in classifications are mainly limited to 1 degree of difference. Incontinence lesions are most often confused with grade 2 (blisters) and grade 3 pressure ulcers (superficial pressure ulcers). Conclusions. The inter‐rater reliability of the European Pressure Ulcer Advisory Panel classification appears to be good for the assessment of photographs by experts. The difference between an incontinence lesion and a blister or a superficial pressure ulcer does not always seem clear. Relevance to clinical practice. The ability to determine correctly whether a lesion is a pressure ulcer lesion is important to assess the effectiveness of preventive measures. In addition, the ability to make a correct distinction between pressure ulcers and incontinence lesions is important as they require different preventive measures. A faulty classification leads to mistaken measures and negative results. Photographs can be used as a practice instrument to learn to discern pressure ulcers from incontinence lesions and to get to know the different grades of pressure ulcers. The Pressure Ulcer Classification software package has been developed to facilitate learning.     

Using the benchmarking process to enhance pressure ulcer prevention

Pressure ulcers are a recognized source of increased debilitation that continually impact on patients' quality of life and the NHS economy. While it remains arguable that all pressure ulcers can be prevented, it could be suggested that with closer monitoring of care provision by the healthcare professionals delivering that care, not only will quality of care be enhanced but a reduction in pressure ulcer incidence is a further potential outcome. The Department of Health prioritised pressure ulcer prevention within Essence of Care and the introduction of clinical benchmarking across a number of care settings demonstrates that care provision relating to pressure ulcer prevention can be enhanced through this process. Clinical benchmarking is an on-going process and should remain an integral component to every day nursing practice in order to sustain this positive phenomenon of change.     

Prevention and management of pressure ulcers in critical patients

The Taiwan Join Commission on Hospital Accreditation identified pressure ulcers as an important clinical care indicator in 2011. Pressure ulcers are a particularly critical medical care issue in hospital intensive care units. Pressure ulcers can influence patient physiology in terms of greater perceived pain, elevated infection and sepsis incidence, increased unplanned surgical treatments, and reduced activities of daily living (ADL). Pressure ulcers can also affect psychology through induced depression, stress, and anxiety. They can also increase patient and societal costs and prolong hospital stay length. This article explores the prevention and management of pressure ulcer in serious illness patients and introduces effective assessment and management techniques. We hope this article raises clinical nurse awareness of this critical issue and helps decrease the incidence of pressure ulcer-related complications in order to enhance overall quality of care.     

Pressure ulcers: the great insult

Pressure ulcers are a common and frustrating problem. Pressure ulcers increase demands on health care resources and are sometimes a source of malpractice litigation. Skin breakdown, often an iatrogenic complication of hospitalization, increases the length of stay and contributes to mortality and morbidity. Long-term care facilities are under increasing regulatory pressure to reduce rates of pressure ulcer occurrence. The process-outcome link continues to escape us. Processes of care seem disjointed. Numerous studies show a failure to implement what we know. When pressure ulcer risk is identified, preventive measures often are not implemented. The literature is replete with reports of quality improvement activities that enumerate multiple opportunities to improve care related to pressure ulcers. Various quality improvement strategies for pressure ulcer prevention and management have been produced, but recommendations are not always applied to practice. When studies compared various outcomes before and after implementation of guidelines, most of the evidence was clinical audit data. Overall, active strategies were associated with better outcomes and passive strategies with poorer ones. Baier et al reported improvement in processes of care after using a structured quality improvement approach in the long-term care setting.Targeted education sessions were common to all studies reporting successful outcomes. Multidisciplinary wound care teams that conduct rounds at the bedside are highly recommended to enhance patient outcomes.Functioning interdisciplinary teams clearly represent an important approach to error reduction. To close the gap between risk identification and pressure ulcer prevention, we should develop active multidisciplinary wound care teams and "Strive for Six Sigma in Pressure Ulcer Care".     

Prevention of Pressure Ulcers in the Surgical Patient

Pressure ulcers (PUs) are a serious health care problem, and it is crucial to assess how patients acquire pressure ulcers after admission to a health care facility. In the OR, factors related to positioning, anesthesia, and the duration of surgery, in addition to patient-related factors, all can affect PU development.This article reviews current practices, including AORN recommended practices, regarding pressure ulcer prevention efforts for surgical patients.All surgical patients should be considered at-risk for pressure ulcer development; therefore, perioperative departments should develop and implement strategic plans for pressure ulcer prevention. AORN J 89 (March 2009) 538-548. © AORN, Inc, 2009.     

Nurses’ pressure ulcer related judgements and decisions in clinical practice: A systematic review

BackgroundPressure ulcers are considered to be an adverse outcome of care that should never occur in clinical practice. The formation of a pressure ulcer is also perceived to be an indicator of poor quality nursing care. Therefore, pressure ulcer prevention is a priority for nurses, healthcare professionals and healthcare organisations throughout the world. A key factor in pressure ulcer prevention and management is individual nurse decision making.ObjectivesTo synthesise the literature on the judgement and decision making of nurses in relation to the assessment, prevention, grading and management of pressure ulcers in all care settings (hospital and community).DesignA systematic search of published literature relating to judgement and decision making in nurses, with a focus on the prevention and management of pressure ulcers.MethodsA search of electronic databases from 1992 to present, together with hand searching of the reference lists of retrieved publications, to identify published papers that reported results of studies evaluating the decision making of nurses in relation to the prevention and management of pressure ulcers. Abstracts were independently reviewed by two authors and full text of potentially relevant articles retrieved. Each paper included in this systematic review was evaluated using recognised appraisal criteria relevant to the specific study design. Included papers provided empirical data on key aspects of nurses’ pressure ulcer related judgements and decision making. Data were synthesised into themes using narrative analysis.ResultsSixteen studies and one systematic review were included in the review, focusing on pressure ulcer risk assessment, pressure ulcer prevention, grading of pressure ulcers and treatment decisions. The results indicated that assessment tools were not routinely used to identify pressure ulcer risk, and that nurses rely on their own knowledge and experience rather than research evidence to decide what skin care to deliver.ConclusionsEmphasising pressure ulcer risk assessment and pressure ulcer grading in clinical practice is unlikely to deliver improved outcomes. Further research into nurses’ pressure ulcer related judgements and decision making is needed and clinicians must focus on the consistent delivery of high quality care to prevent and mange pressure ulcers to all patients in clinical practice.     

Principles for pressure ulcer prevention in the community

This article aims to examine the prevention of pressure ulcers in the community. Pressure ulcers continue to cause needless distress and anxiety for patients, carers and their families. Health professionals in the community often face extreme challenges when caring for patients who are at risk of developing pressure ulcers. This could be due to lack of appropriate assessment skills and having insufficient time to conduct an appropriate assessment. Having an understanding and awareness of the function of the skin and the aetiology of pressure ulcer development can assist the health professional in attempting to take a proactive approach to prevent pressure ulcer formation in the community setting.     

可免性和难免性压疮定义分析及启示

查阅国内外文献，解读和分析现有的可免性和难免性压疮定义产生的背景及其内涵、代表性和适用性，结合我国医院内压疮管理现状，提出管理建议：一是建立压疮调研制度，动态了解压疮预防现况；二是修订适合我国国情的可免性和难免性压疮的鉴定标准，以准确判断，规避风险。     

Pressure Ulcers, Part 1: Prevention Strategies

Pressure ulcers are a costly health concern. Many can be prevented by conscientious, vigorous nursing care. The nurse practitioner (NP) is an ideal professional to direct preventive care and to manage the treatment of ulcers. This article reviews the multiple risk factors and dynamics involved in the development of pressure ulcers, and preventive measures that can be implemented. The role of an NP related to pressure ulcer prevention and specific NP interventions are discussed.     

Pressure ulcer risk assessment and prevention

Pressure ulcers were once viewed as an inevitable consequence of being infirm and bed-ridden. As it has been recognized that this is not the case, pressure ulcers have come to be seen much more as an indicator of the quality of care provided, and are consequently high on the political and health agenda. This article provides an overview of the key aspects of pressure ulcer risk assessment and prevention drawn from a variety of national policy documents.     

Pressure ulcer prevalence and incidence in intensive care patients: a literature review

Background: Pressure ulcers remain a common health problem worldwide within the different health‐care settings, especially in intensive care settings. Aims: The aims of this were to systematically assess the recent prevalence and incidence of pressure ulcers in intensive care patients (2000–2005), the factors related to pressure ulcer prevalence and incidence and the methodological rigour of studies about pressure ulcer prevalence and incidence in intensive care patients. Methods: The research design involved a review of literature for the period of 2000 to 2005, focused on the prevalence and incidence of pressure ulcers in intensive care patients. Results: The analysis of published papers revealed variations in pressure ulcer prevalence in intensive care settings ranging from 4% in Denmark to 49% in Germany, while incidence ranged from 38% to 124%. There was a wide variation in the prevalence and incidence of pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in the prevention and treatment of pressure ulcers which needs to be addressed. Conclusion: Further research is needed regarding the effectiveness of nursing care on pressure ulcer development and into treatments that may successfully prevent their occurrence in intensive care patients.     

Pressure ulcer prevention in critical care: state of the art

Prevention of pressure ulcers in the critically ill patient is a major responsibility of the critical care nurse. The authors review the causes of pressure ulcer development and the methods of identifying the patient at increased risk. Pressure relief strategies for use in critical care are presented, and currently available pressure reduction and relief devices are discussed. Because few research studies address pressure ulcer prevention in the critical care setting, future research in this area is needed to develop a reliable predictive tool for use with the critically ill patient. Level of risk needs to be linked with intervention to assist the nurse in managing the pressure relief options available in today's market. In the meantime, prevention of pressure ulcers in critical care patients requires vigilance and the best use of available knowledge in the field.     

Impact of Pressure Ulcers on Individuals Living With a Spinal Cord Injury

ObjectiveTo describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI).DesignCross-sectional study.SettingNationwide survey.ParticipantsParticipants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%–36.3%) had a pressure ulcer over the last 12 months.InterventionsNot applicable.Main Outcome MeasuresMeasures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0.ResultsOf the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05).ConclusionsPressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.