Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units

OBJECTIVE: Evaluating the prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units (ICUs). DESIGN: Cross-sectional design. SETTING: ICUs of acute care hospitals that participated in the 1998 and 1999 national prevalence surveys. Data were collected on 1 day in each year. PATIENTS: Eight hundred fifty patients admitted to Dutch ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six categories of data were collected: (1) characteristics of the institution, (2) characteristics of the ward, (3) characteristics of the patients (age, sex, date of admission, reason for admission), (4) risk assessment using the Braden scale and two additional risk factors (malnutrition and incontinence), (5) severity of the pressure ulcers and (6) supportive surface used. The prevalence of pressure ulcers was 28.7%. In a forward logistic regression analysis, four risk factors were significantly associated with the presence of pressure ulcers: infection, age, length of stay and total Braden score. Of the patients at high risk of developing pressure ulcers but without actual pressure ulcers, 60.5% were positioned on a support system. Only 36.8% of the patients who were determined to need repositioning were actually being turned. CONCLUSIONS: The prevalence of pressure ulcers in Dutch ICUs is high and their prevention is flawed, especially as regards the use of support systems. Patients for whom turning is indicated are not being turned. Predicting pressure ulcers in ICU patients is difficult and needs further investigation.     

Differences in prevalence of pressure ulcers between the Netherlands and Germany--associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes

Aim. This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background. Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the population’s vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. Method. In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. Results. In-patients of 29 German (n = 2531) and 71 Dutch (n = 10 098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10 237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8·1 times higher for Dutch nursing home residents than for German residents. Conclusion. Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. Relevance to clinical practice. The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines.     

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

Aim To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. Methods A cross‐sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. Results The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure‐reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%). Conclusions Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence‐based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.     

Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany – adjusted for personal risk factors and institutional quality indicators

Background Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence. Methods Data of a binational multi‐centred cross‐sectional study in 103 hospitals (n = 21 378 patients) and 129 nursing homes (n = 15 579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators. Results The prevalence of pressure ulcers among the at‐risk group (Bradenscore ≤20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2–5.7)]. In hospitals, the prevalence among the at‐risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2–1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0–9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4–3.0). Conclusion A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.     

Pressure ulcers: implementation of evidence-based nursing practice

AIMS: A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. BACKGROUND: The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. METHOD: The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. RESULTS: Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. CONCLUSIONS: There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.     

Variation in pressure ulcer prevalence and prevention in nursing homes: A multicenter study

AimTo estimate the prevalence of pressure ulcers in nursing homes and its variability, the frequency of use of preventive measures and treatment.BackgroundPressure ulcer is a frequent pathology across healthcare settings. Most pressure ulcers are preventable and are considered an important quality of care indicator.MethodsAssessments were done on a single day of November 2015 in nursing homes in Geneva, Switzerland. Of the 51 institutions (3824 patients) eligible, 33 homes agreed to participate, representing 2671 patients (69.8%).One referent nurse per nursing home received training on pressure ulcer detection. To estimate the residual variability in prevalence and in number of prevention measures, adjusted multilevel logistic regressions were used.ResultsPatients were on average 85.6 years old, with a median length of stay of 2.1 years. The overall prevalence was 5.7% but varied considerably, from 0% to 19.6%.The variability across nursing homes decreased slightly when taking into account patient-level and institution-level characteristics.In the adjusted models, pressure ulcers prevalence was significantly associated with Braden risk; number of preventive measures was significantly associated with nursing home size, and Braden risk, and marginally associated with length of stay.ConclusionsOverall prevalence of pressure ulcers was relatively low. While several prevention measures for patients at risk were taken, the correct use of all of them was rare.The variability in prevalence and in number of preventive measures across nursing homes was very high. Programmes focusing on the correct use of all recommended prevention measures could help reducing pressure ulcers prevalence.     

Pressure ulcer prevalence in Europe: a pilot study

RATIONALE AND AIMS: Numerous prevalence studies have been conducted. The problem with these studies is that prevalence proportions cannot be compared with each other, because of differences in performance of each survey. There is no agreed standardized method for determining prevalence proportions. This study aimed to develop and pilot a uniform data collection instrument and methodology to measure the pressure ulcer prevalence and to get some insight into pressure ulcer prevalence across different patient groups in Europe. METHODS: Pressure ulcer experts from different European countries developed a data collection instrument, which included five categories of data: general data, patient data, risk assessment, skin observation and prevention. A convenience sample of university and general hospitals of Belgium, Italy, Portugal, UK and Sweden participated in the study. In each participating hospital, teams of two trained nurses who collected the data on the wards were established. All patients admitted before midnight on the day of the survey and older than 18 years were included. RESULTS: The data collection instrument and study procedure of the survey were found to be effective by all participants. 5947 patients were surveyed in 25 hospitals in five European countries. The pressure ulcer prevalence (grade 1-4) was 18.1% and if grade 1 ulcers were excluded, it was 10.5%. The sacrum and heels were the most affected locations. Only 9.7% of the patients in need of prevention received fully adequate preventive care. CONCLUSION: The methodology is sufficiently robust to measure and compare pressure ulcer prevalence in different countries. The pressure ulcer prevalence was higher than expected and relatively few patients received adequate prevention. This indicates that more attention to prevention is needed in Europe.     

肿瘤患者压力性损伤患病率的系统评价

目的 系统评价肿瘤患者压力性损伤的患病率,为压力性损伤的防治决策提供依据.方法 计算机检索CNKI、WanFang Data、VIP、CBM、PubMed、EMbase、Cochrane Library、Web Of Science,收集有关肿瘤患者压力性损伤患病情况的相关研究.检索时限从建库至2019年9月,经逐层筛...     

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.     

Preventing and managing heel pressure ulceration: an overview

Heel pressure ulcers are the second most common site for pressure ulceration; although their assessment and treatment can be complex, and they often require additional consideration over and above core principles of pressure ulcer prevention and management. Recent international pressure ulcer prevention and treatment guidelines developed jointly in Europe and the USA have provided greater clarity by achieving international consensus on how to care for patients at risk of heel pressure ulceration, and also on the management of such patients if a pressure ulcer develops. Health professionals should embrace these guidelines and embed them in their everyday clinical practice and within local guidance and protocols to ensure that patients are provided with evidence-based care supported by international collaboration and agreement.     

Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial

BackgroundPressure ulcers cause suffering to patients and costs to society. Reducing pressure at the interface between the patient's body and the support surface is a valid clinical intervention for reducing the risk of pressure ulcers. However, studies have shown that knowledge of how to reduce pressure and shear and to prevent pressure ulcers is lacking.ObjectiveTo evaluate the effect of a pressure mapping system on pressure ulcer prevalence and incidence in a hospital setting.DesignPragmatic randomised controlled trial.SettingA geriatric/internal medical ward with 26 beds in a Swedish university hospital.Participants190 patients were recruited (intervention: n = 91; control: n = 99) over a period of 9 months. Patients were eligible if they were over 50 years old, admitted to the ward between Sunday 4 pm and Friday 4 pm, and expected to stay in the ward ≥3 days.InterventionThe continuous bedside pressure mapping system displays the patient's pressure points in real-time colour imagery showing how pressure is distributed at the body–mat interface. The system gives immediate feedback to staff about the patient's pressure points, facilitating preventive interventions related to repositioning. It was used from admittance to discharge from the ward (or 14 days at most). Both intervention and control groups received standard pressure ulcer prevention care.ResultsNo significant difference in the prevalence and incidence of pressure ulcers was shown between intervention and control groups. The prevalence of pressure ulcers in the intervention group was 24.2% on day 1 and 28.2% on day 14. In the control group the corresponding numbers were 18.2% and 23.8%. Seven of 69 patients (10.1%) in the intervention group and seven of 81 patients (8.6%) in the control group who had no pressure ulcers on admission developed category 1 and category 2 ulcers during their hospital stay. The incidence rate ratio between the intervention and control groups was 1.13 (95% CI: 0.34–3.79).ConclusionsThis study failed to demonstrate a beneficial effect of a pressure mapping system on pressure ulcer prevalence and incidence. However, the study could have increased staff awareness and focus on pressure ulcer prevention, thus affecting the prevalence and incidence of pressure ulcers in a positive way in both study groups. It is important to further investigate the experience of the multidisciplinary team and the patients regarding their use of the pressure mapping system, as well as strengths and weaknesses of the system.     

Pressure relief bedding to prevent pressure ulcer development in critical care

One major risk for the critically ill patient is the development of pressure ulcers during the intensive care unit (ICU) stay. These patients have many of the risk factors for the development of pressure ulcers including reduced mobility/activity, medications, neurologic deficits, increasing age, incontinence, decreased mental status, poor nutrition, pressure, shear forces, and friction. Pressure ulcers are known to be costly for the health care system and delay recovery in many patients. Different strategies have been advocated for the prevention of pressure ulcers, and the Agency for Healthcare Research and Quality (AHRQ) has identified the use of pressure relief bedding as a means to prevent the development of pressure ulcers during hospitalization. The use of pressure relief bedding has received the most research attention to date. The focus of this article is to describe the state of the current research in this area and how this applies to critical care. Development of protocols and guidelines for the use of pressure ulcer preventing strategies are important to improve the quality of care in the ICU.There is still a need to examine the impact of the evidence of pressure ulcer prevention in the ICU and this review should help to build a framework for future research and protocol development.     

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.     

综合性医院压疮现患率多中心联合调研

目的:获得综合性医院住院成人患者的压疮现患率和医院获得性压疮发生率,为下一步预防策略的制定提供依据。方法:采用统一的调研时间、工具、方法、流程及判断标准,组织统一培训合格的护士457名对12所综合性医院≥18岁的住院患者实施横断面调研,统计压疮现患率和医院获得性压疮发生率,采用SPSS16.0统计软件进行描述性统计分析。结果:压疮现患率为1.579%,医院获得性压疮发生率为0.628%。压疮现患率排序前三位科室分别为ICU、老年科、神经内科,医院获得性压疮发生率排序前三位科室分别为ICU、老年科、内科;前三位年龄分别为>89岁、80～89岁、70～79岁;前三位压疮部位分别为骶尾部、足跟部、髂嵴;前三位发生时段为不清楚发生时间、8∶00-12∶00和2∶00-8∶00。结论:本研究所获得的压疮现患率和发生率可代表我国部分地区住院患者的基线值。≥70岁者是压疮预防的重点对象;骶尾部、足跟部和髂嵴部是压疮重点防护部位;ICU、老年科和内科是重点预防科室;8∶00-12∶00和2∶00-8∶00是重点预防时段,值得注意的是有76.545%的压疮发生时段不清楚,因此需要加强护士的压疮预防意识并严格执行交接班制度,按要求检查皮肤。     

Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation

The aims were to investigate (i) registered nurses' and nursing assistants' knowledge of risk, prevention and treatment of pressure ulcer before implementing a system for risk assessment and pressure ulcer classification for patients with hip fracture (ii) interventions documented in the patient's records by registered nurses, and (iii) to what extent reported and documented interventions accord with the Swedish quality guidelines. Nursing staff (n=85) completed a questionnaire, and patient's records (n=55) were audited retrospectively. The majority of the nursing staff reported that they performed risk assessment when caring for a patient with hip fracture. These risk assessments were, however, not comprehensive. The most frequently reported preventive interventions were repositioning, use of lotion, mattresses/overlays and cushions for the heels. These interventions were to some extent documented in the patient's records. Nutritional support, reduction of shear and friction, hygiene and skin moisture, and patient's education were reported to a small extent and not documented at all. The Swedish quality guidelines regarding prevention and treatment of pressure ulcers were not fully implemented in clinical practice. It was concluded that nursing staff's knowledge and documentation of risk, prevention and treatment of pressure ulcers for patients with hip fractures could be improved.     

Pressure ulcer prevention in intensive care patients: guidelines and practice

Background  Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention.
Design  The design of this study was a cross-sectional study (point prevalence).
Setting  The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards.
Results  The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients.
Conclusions  The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.     

Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers

Background. In the Netherlands much attention has been paid to pressure ulcer prevention. National guidelines on pressure ulcer prevention were developed in 1985 and adapted in 1992 at the request of a national organization for quality assurance in health care. Several studies indicate that nurses seem to be insufficiently informed about pressure ulcer preventive activities. There is, however, no information available about the reasons why nurses seem to be insufficiently informed. Aims and objectives. This study was planned to elucidate the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention and about issues related with pressure ulcer prevention. Design. A qualitative study with semi‐structured, tape‐recorded interviews. Method. Interviews were conducted with enrolled nurses, team leaders, head nurses, staff nurses and physicians. The interviews were coded and analysed. Results. Analysis of the interviews revealed that today's pressure ulcer preventive activities are very much based on old traditions in nursing. It also showed that enrolled nurses have no intention to change the care they deliver with regard to pressure ulcer prevention. Conclusions. It is concluded that a systematic approach is necessary to change nursing thinking and acting with regard to pressure ulcer prevention. Relevance to clinical practice. This study gives an overview of the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention. These views and beliefs can be used as a starting point for effective implementation of guidelines regarding the prevention of pressure ulcers.     

A comparison of pressure ulcer prevalence rates in nursing homes in the Netherlands and Germany, adjusted for population characteristics

Annual pressure ulcer surveys in the Netherlands and Germany have shown remarkable differences in prevalence rates. We explored the differences between the two populations, and the degree to which these differences were associated with differences in prevalence. To this end, data from 48 Dutch and 45 German facilities (n = 9772) from 2003 were analyzed. The prevalence of pressure ulcers (excluding grade 1) was 12.5% in the Netherlands and 4.3% in Germany. After adjusting for age, sex, and other risk factors, the probability of developing a pressure ulcer of stage 2 or higher in Dutch nursing homes was three times greater than in German homes.