Pressure injury prevalence and incidence in acute inpatient care and related risk factors: A cross‐sectional national study

The aim of this national cross‐sectional study was to explore the prevalence of pressure injuries and incidence of hospital‐acquired pressure injuries, and the relating factors in somatic‐specialised inpatient care in Finland. The study was conducted in 16 (out of 21) Finnish health care organisations offering specialised health care services. Data were collected in 2018 and 2019 from adult patients (N = 5902) in inpatient, emergency follow‐up, and rehabilitation units. Pressure injury prevalence (all stages/categories) was 12.7%, and the incidence of hospital‐acquired pressure injuries was 10%. Of the participants, 2.6% had at least one pressure injury at admission. The risk of hospital‐acquired pressure injuries was increased for medical patients with a higher age, the inability to move independently, mode of arrival, being underweight, and the absence of a skin assessment or pressure injury risk assessment at admission. For surgical patients, the risk was associated with the inability to move independently, mode of arrival, and lack of skin assessment at admission, while being overweight protected the patients. Overall, medical patients were in greater risk of hospital‐acquired pressure injuries than the surgical patients. An assessment of the pressure injury risk and skin status should be carried out more systematically in Finnish acute care hospitals.     

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The group's main findings are summarised in this paper.     

Use of a total quality management model to reduce pressure ulcer prevalence in the acute care setting

As the population ages and becomes more frail, pressure ulcer prevalence and incidence within specific care settings are being evaluated through outcomes review. This article summarizes the process and outcomes of an ongoing prevalence study at a 300-bed acute care community hospital. All patients on the adult medical, surgical, and critical care units were examined regularly by the “Rear Admirals,” a team comprising a skin care resource person and a nursing unit representative. The Total Quality Management model, characterized by the phrase “Plan-Do-Check-Act,” was used to address barriers to quality care. Findings during that time prompted changes in policies, products, protocols, work assignments, and documentation tools. The outcomes achieved demonstrate the effectiveness of those strategies. After implementation of the Total Quality Management model at our institution, the prevalence of patients with nosocomial pressure ulcers was reduced by 83%.     

Risk factors for pressure ulcers in acute care hospitals

Selection of patients for preventive measures to protect against pressure ulcers relies on clinical scales and provider judgment, which vary widely. Our objectives were to: (a) identify risk factors by clinical classification and report demographic differences in pressure ulcer risk and (b) develop criteria for identification of high-risk patients. Patients with pressure ulcer as a discharge diagnosis were identified from the 2003 Nationwide Inpatient Sample (NIS). The effect of discharge diagnosis was examined using the Agency for Healthcare Research and Quality Clinical Classification Software (CCS). Multiple regression analysis for survey data was used to assess risk factors. The 2003 NIS listed 94,758 with a discharge diagnosis of pressure ulcer, identified as International Classification of Disease-9 code 707.0–707.09, for an overall incidence of 143 per 10,000. Forty-five CCS discharge diagnoses were present in at least 5% of these patients and 28 of these CCS diagnoses had odds ratios >2.0. African-American race and advanced age were identified as risk factors for pressure ulcer diagnosis. Disorders of skin integrity, organ system failure, and infection were found to be broad categories of risk factors as well. Using the NIS, risk factors for pressure ulcer including diagnoses and demographic factors have been identified.     

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9‐year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual‐care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital‐acquired pressure ulcers decreased following implementation of an evidence‐based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual‐care nurses under‐estimated patients' risk of pressure ulcer development and under‐utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital‐acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.     

Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study

The purpose of this study was to identify pressure ulcer (PU) incidence and risk factors that are associated with PU development in patients in two adult intensive care units (ICU) in Saudi Arabia. A prospective cohort study design was used. A total of 84 participants were screened second daily basis until discharge or death, over a consecutive 30‐day period, out of which 33 participants with new PUs were identified giving a cumulative hospital‐acquired PU incidence of 39·3% (33/84 participants). The incidence of medical devices‐related PUs was 8·3% (7/84). Age, length of stay in the ICU, history of cardiovascular disease and kidney disease, infrequent repositioning, time of operation, emergency admission, mechanical ventilation and lower Braden Scale scores independently predicted the development of a PU. According to binary logistic regression analyses, age, longer stay in ICU and infrequent repositioning were significant predictors of all stages of PUs, while the length of stay in the ICU and infrequent repositioning were associated with the development of stages II–IV PUs. In conclusion, PU incidence rate was higher than that reported in other international studies. This indicates that urgent attention is required for PU prevention strategies in this setting.     

Pressure ulcer prevalence and incidence, instructions for use

Pressure ulcer prevalence and incidence surveys are more and more frequently conducted and used as indicators in order to evaluate healthcare quality and effectiveness of implementation of prevention measures (guidelines and recommendations). The ever-increasing use of such surveys over the last ten years justifies the necessity for a better understanding of definitions and what can be expected from these results in order to optimise their use as epidemiological indicators.     

A prospective national study of acute renal failure treated with RRT: incidence, aetiology and outcomes.

BACKGROUND: Acute renal failure (ARF) is a diverse condition with no standardized definition and is managed in several sub-specialty areas within hospitals. Its incidence and aetiology are unknown and studies show a wide range of incidences. ARF is becoming more common as the population ages leading to the hypothesis that the incidence is much higher than previous estimates. METHODS: This prospective population study investigated the incidence, aetiology and outcomes of ARF based on a standardized classification of ARF treated by renal replacement therapy (RRT) in all sub-specialty areas within hospitals where such treatment takes place. Data were collected prospectively on all patients starting RRT for ARF within three 12-week periods in 2002. RESULTS: Two hundred eighty-six adults per million population (pmp) per year received RRT for ARF. The incidence increased with age and pre-existing comorbid illness. Two hundred twelve adults pmp per year had no evidence of pre-existing chronic kidney disease (CKD) and the remainder had acute on CKD. The median age was 67 years. Fifty-one percent of the patients received their first RRT treatment in a critical care setting. Sepsis was the most common aetiological insult contributing to ARF in 48% of the patients. Mortality was high with 48% dying within 90 days of starting RRT. Age, comorbidity, sepsis and recent surgery were independent risk factors for death in those with no pre-existing CKD. DISCUSSION: This is the first national study to describe ARF treated with RRT in all hospital locations. The hypothesis that ARF occurs more frequently than previously thought has been confirmed. This study provides data upon which to base effective decision making for prevention, patient care and resource planning for patients with ARF.     

The effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting.

The Braden score is a reliable predictor of a patient's potential for developing pressure ulcers. Moisture is 1 of 6 indicators considered when calculating a Braden score. Efforts to reduce the effects of moisture and enzymatic activity on skin from incontinent diarrhea have employed various types of nonstandardized and nonapproved approaches. Rigid rectal tubes and catheters designed for other purposes are among the devices being utilized. These devices may put the patient at risk for rectal necrosis and loss of sphincter tone, and their use has produced no demonstrable positive outcomes. Additionally, their use is limited to those patients who are experiencing active diarrhea. The Zassitrade mark Bowel Management System (BMS) developed by Zassi Medical Evolutions, Inc., has produced promising outcomes. While the BMS is useful in managing patients with diarrhea, it can also be used to modify formed stool in patients who have wounds that are likely to become contaminated with incontinent feces, or who are too hemodynamically unstable to turn for lengthy or frequent incontinence care.     

Stability in incidence of acute appendicitis. A population-based longitudinal study

BACKGROUND/AIM OF THE STUDY: During the past 50 years, a decrease in incidence of appendicitis has been reported. The various studies were retrospective and based on different data sources. In the present study, we analyze prospectively the incidence of acute appendicitis during a 10-year period in a well defined population of 265,000. METHODS: Prospective registration of all operations performed in patients with suspected acute appendicitis in the catchment area of a single institution. The diagnosis of acute appendicitis was based on histology in all cases. The annual incidence of acute appendicitis was calculated with regard to nonperforated and perforated acute appendicitis. MAIN RESULTS: Between 1989 and 1998, 2,861 patients underwent surgery for suspected acute appendicitis. In 2,232 (78%) patients, acute appendicitis was confirmed histologically. Mean annual incidence was 84/100,000 (95% confidence interval 80 to 88/100,000). Crude incidence remained stable during the study period, with the exception of a significant increase in 1991 followed by a significant decrease the next year. Nonperforated acute appendicitis showed a different incidence pattern as compared to perforated acute appendicitis. CONCLUSION: In our prospective study, the incidence of acute appendicitis remained stable in our well-defined study population during the study period of 10 years. This is in contrast to the majority of studies during the last decades.     

African Americans show increased risk for pressure ulcers: A retrospective analysis of acute care hospitals in America

In an earlier study, we reported a significantly increased risk of pressure ulcer hospital discharge diagnoses in African Americans, higher age groups, and those with certain medical conditions. The objectives of the present study were to: (a) investigate the demographics associated with a higher odds ratio (OR) in African Americans and (b) determine whether African Americans have different rates of medical risk factors. The 2003 Nationwide Inpatient Sample database was queried. Patients with pressure ulcers were identified by discharge diagnoses using ICD-9 codes 707.0–707.09. Discharge diagnosis was examined using the agency for healthcare research and quality clinical classifications software (CCS). The present study used identified CCS discharge diagnoses present in at least 5% of all patients, with an OR>2. African Americans exhibited a higher incidence of an OR>2 for 28 identified CCS risk factors for pressure ulcers. The pressure ulcer diagnoses tended to occur at younger ages in African Americans. No significant differences were noted in African Americans with pressure ulcers when a subanalysis was conducted by zip code income quartile, region of the country, or teaching status of the hospital. Hospitalized African Americans exhibit an age-dependent, higher prevalence of pressure ulcers compared with Caucasians. Socioeconomic factors tracked within the Nationwide Inpatient Sample do not provide an explanation for this phenomenon.     

基于JCI标准的医院压疮现患率和院内压疮发生率调查

目的监测分析我院压疮现患率和院内压疮发生率的基线资料和变化趋势,促进压疮护理质量改进,降低压疮发生率。方法采用JCI（I-NSC-2）和NDNQI中的压疮事件数据收集工具,每季度对住院患者压疮现患率和院内压疮发生率进行横断面调查。结果我院压疮现患率为1．36％～2．63％,院内压疮发生率0．45％～1．13％;监护室的压疮现患率为10．53％～29．41％,院内压疮发生率为5．00％～15．69％,为我院的压疮高发部门。结论监护室的压疮预防应作为医院护理质量改进的重点项目,要重视监护室的质量监控;定期开展医院压疮现患率和院内压疮发生率的调查,可获得压疮护理质量监控的基线数据和变化趋势,为今后评价和研究压疮护理质量提供依据。     

Peer-to-peer nursing rounds and hospital-acquired pressure ulcer prevalence in a surgical intensive care unit: a quality improvement project

We conducted a quality improvement project in order to evaluate the effect of nurse-to-nurse bedside "rounding" as a strategy to decrease hospital-acquired pressure ulcers (HAPU) in a surgical intensive care unit. We instituted weekly peer-to-peer bedside skin rounds in a 17-bed surgical intensive care unit. Two nurses were identified as skin champions and trained by the hospital's certified WOC nurse to conduct skin rounds. The skin champion nurses conducted weekly peer-to-peer rounds that included discussions about key elements of our patients' skin status including current Braden Scale for Pressure Sore Risk score, and implementation of specific interventions related to subscale risk assessment. If a pressure ulcer was present, the current action plan was reevaluated for effectiveness. Quarterly HAPU prevalence studies were conducted from January 2008 to December 2010. Nineteen patients experienced a HAPU: 17 were located on the coccyx and 2 on the heel. Ten ulcers were classified as stage II, 3 PU were stage IV, 5 were deemed unstageable, and 1 was classified as a deep tissue injury. The frequency of preventive interventions rose during our quality improvement project. Specifically, the use of prevention surfaces increased 92%, repositioning increased 30%, nutrition interventions increased 77%, and moisture management increased 100%. Prior to focused nursing rounds, the highest HAPU prevalence rate was 27%. After implementing focused nursing rounds, HAPU rates trended down and were 0% for 3 consecutive quarters.     

EPUAP pressure ulcer prevalence survey in Sweden: a two-year follow-up of quality indicators.

OBJECTIVE: The aim of this study was to determine the effects of quality improvement programs for pressure ulcer prevention by conducting a follow-up survey in a hospital in Sweden. DESIGN: A cross-sectional survey design with comparison between data collected in 2002 and 2004. SETTING AND SUBJECTS: All inpatient areas were surveyed in the surgical, medical, and geriatric departments in a university hospital. A total of 369 patients were included. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form including some additional questions. METHODS: The 1-day survey was conducted on March 23, 2004. Each patient was visited by 2 registered nurses, who inspected the patient's skin for any pressure ulcer classified according to the EPUAP grading system. RESULTS: There were no significant differences in gender, age, or Braden score between the patients in surgical, medical, or geriatric care in 2002 and 2004. The overall prevalence of pressure ulcers was 33.3% (grade 1 excluded: 10.9%) in 2002 and 28.2% (grade 1 excluded: 14.1%) in 2004. In surgical care, the prevalence was reduced from 26.8% to 17.3% (P = .051). In medical care, the prevalence was 23.6% in 2002 and 26.7% in 2004. Corresponding prevalence figures for geriatric care were 59.3% and 50.0%. A quarter of the patients in surgical care, a third in medical care, and more than half in geriatric care had a pressure ulcer upon arrival at the ward. The use of pressure-reducing mattresses had increased significantly from 16.0% to 42.7% in medical care (P = .000). CONCLUSIONS: The EPUAP methodology has facilitated the introduction of pressure ulcer as a quality indicator at hospital level. Pressure ulcer prevalence surveys with a standardized methodology should be repeated on a regular basis in order to stimulate quality improvement.