Monitoring the pressure sore problem in a teaching hospital

During 1989 and 1990 a senes of three prevalence surveys were undertaken in a West Midlands teaching hospital to identify the numbers of patients at risk of developing pressure sores and the actual number of patients with pressure sores, prior to the purchase of pressure relieving equipment A further survey was undertaken in January 1993 to examine any improvement in pressure sore prevention strategies and in the care of those with established pressure sores All in-patients were assessed using the Waterlow score Full details of all pressure sores and any pressure relieving equipment in use was recorded The findings were compared with those of the first survey in 1989 The prevalence for 1989 was 8 77%, and this had reduced slightly to 7 9% in 1993 There was no significant difference in these figures However, in 1989 35 patients had 64 pressure sores and in 1993 32 patients had 46 pressure sores There was a significant reduction in the actual numbers of pressure sores There was no significant difference in the grades of sores and the sacrum was the most frequent position in both surveys The survey showed an improvement in the management of established pressure sores There was little change in the patient populations with respect to the degree of risk of pressure sore development Using the Waterlow score, the numbers of patients found to be in the no risk, at risk, high risk and very high risk categories remained remarkably stable These surveys will continue to provide a basis for selecting pressure relieving equipment Measurement of pressure sore incidence is needed in the future to monitor the efficacy of the prevention programme     

Pressure sore prevalence within a public health services area

Pressure sores are a great problem for patients, staff and society. The aim of this study was to examine the prevalence, treatment and prevention of pressure sores in a public health service area in Sweden. Criteria used for pressure sore assessment were persistent discoloration, epithelial damage and damage to the full thickness of the skin, without or with a cavity. The data were collected during 2 weeks in April 1995 from 1173 inpatients. The pressure‐sore prevalence rate was 3.75%; 44 patients had a total of 68 sores. Men were as prone to developing pressure sores as women. The most frequently reported preventive measures were antidecubitus mattresses and turning schedules. Relief from pressure and occlusive dressings were the most common treatment measures. There was no statistical difference in pressure‐sore prevalence when compared with a similar study from 1980. Patients were, however, older in 1995.     

The prevalence of pressure sores within an area health authority

A point prevalence survey carried out to determine the number of pressure sores within the Nottingham Health Authority revealed that 5.3% patients were affected (132 patients out of 2513). The majority of patients were elderly (80.3% aged over 65), female (76.5%), and either categorized as immobile or having very limited mobility (77.2%). There were 233 pressure sores, 54.9% of which were on the buttocks or sacrum, and 24.9% of which were on or near the heels and ankles. Nine different cleansing agents were in use, 31 different preparations were applied to the sores and nine types of dressings were employed, with little standardization of use. The most popular aids used for the relief of pressure areas included synthetic sheepskin pads (supplied to 46.2% of the affected patients) and ripple mattresses (supplied to 28.8% of the affected patients). The prevalence of pressure sores within the health authority is indicated. These findings are similar to those of a previous study and may be applicable to other health areas.     

Setting the standard for pressure sore prevention on a trauma orthopaedic ward

This article describes an innovation used to tackle the problem of high prevalence and severity of pressure sores on an orthopaedic trauma ward. Simple data from the pressure sore prevalence survey were used to build the case and provide the rationale for action. Actions taken included targeting the elderly with hip fractures and having the prevention strategy start in Accident and Emergency (A&E) Department. A standard with a monitoring tool was devised at ward level to review and monitor our practice in pressure sore prevention. This has resulted in the reduction of the prevalence rate of pressure sores on the ward from 21% to 8% over four years. The severity of pressure sores also decreased.     

Patients admitted with decubital lesions: the experience of the Milanese hospital in Garbagnate

Patients may develop a pressure sore while in hospital, but some are admitted with a pressure sore. In Garbagnate hospital all patients are assessed for the risk of pressure sores. The ad hoc forms of patients with multiple lesions, in very poor conditions and with "sentinel" symptoms such as poor hygiene, malnutrition, bruises, are specifically assessed and further data from the head nurse and the family are collected to understand and reconstruct the patients' stories. From January 1999, 26 patients with pressure sores were admitted; 80% were over 75 years: 42.4% came from their homes and 7 from nursing homes. Half of the patients presented severe malnutrition. All the cases had some common characteristics: lack of well defined management of pressure sores; delays in the requests for special mattresses due to lack of attention or bureaucratic problems; or use of ineffective treatments or medications; lack of contacts between hospital and district, leading to a fragmented patient care. Two of the 26 cases are presented and their significance discussed in details.     

Bed surfaces and pressure sore prevention: an abridged report

PURPOSE: This article summarizes the results of a systematic review of randomized controlled trials testing the effectiveness of special beds, mattresses, and cushions in preventing and treating pressure sores. The review's citation is Cullum, N., Deeks, J., Sheldon, T.A., Song, F., & Fletcher, A.W. (2000). Beds, mattresses and cushions for pressure sore prevention and treatment (Cochrane Review). The Cochrane Library, 4. DESIGN: An integrative research review. SAMPLE: 37 studies were included in the analysis. METHODS: A broad search of databases and unpublished studies was conducted. Data were extracted from those that met the inclusion criteria. Studies were grouped in various ways but mainly by type of product evaluated. FINDINGS: Many special products designed to prevent or treat pressure sores are more effective than standard hospital foam mattresses in preventing and treating pressure sores. CONCLUSIONS: Special pressure-relieving surfaces should be used for patients at risk for skin breakdown. IMPLICATIONS FOR NURSING PRACTICE: Individual practitioners and agencies should have a systematic protocol for assessing patients' risk of skin breakdown and for taking action when patients are determined to be at risk. The findings of this review provide some guidance for choosing particular products, albeit not definitive evidence for matching risk levels to products.     

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.     

压疮管理系列表格的设计与应用

目的 探讨压疮管理系列表格的实用性及在提高护士高危压疮和院外带入压疮上报符合率、压疮护理记录书写合格率中的作用和效果.方法 将2010年上报的高危及院外带入压疮433例作为观察组,将2009年上报的高危及院外带入压疮205例作为对照组.设计和应用压疮管理系列表格,包括高危压疮评估表、高危压疮申报单、院外压疮呈报表、压疮防治护理记录单等4种压疮管理表格,采用表格、图示、说明等辅助设计,并应用于观察组中,比较2组各项指标.结果 与对照组相比,观察组的高危压疮及院外带入压疮上报符合率、压疮护理记录书写合格率、压疮治愈和好转率提高,高危压疮发生数显著减少.结论 压疮管理系列表格有助于护士准确评估高危压疮及院外带入压疮,有助于提高压疮治愈、好转率及护士书写压疮护理记录的质量.

Abstract：

Objective To explore the practicability of the pressure sore management forms and its effect on improving the nurses' reported compliance rates on high-risk pressure sores and external pressure sores and the passing rate of nursing records. Methods With aided designs as forms, icons and notes,making a comparative analysis on high-risk pressure sores and external pressure sore between 433 cases in 2010(the observation group) and 205 cases in 2009(the control group). Designing and applying the pressure sore management forms, including four kinds of forms: the high-risk assessment form, high-risk pressure sores declaration sheet, the external pressure sore report form, pressure sore prevention and care record sheet, then applied them in the observation group. Results Compared with the control group, all aspects like the compliance rates of nurses' reports on high-risk pressure sores and external pressure sore, the passing rate of nursing records, the healing and improvement rates were obviously increased, the occurrence rate of high-risk pressure sores decreased. Conclusions The pressure sore management forms can help nurses for accurate assessing high-risk pressure sores and external pressure sores, also can help to increase the healing and improvement rate and to enhance the quality of nursing records.     

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.     

The size of the pressure-sore problem in a teaching hospital

A series of three prevalence surveys were undertaken in a teaching hospital (where medical students are taught) in the West Midlands of England to identify the numbers of patients at risk of developing pressure sores and the actual number of patients with pressure sores, prior to the purchase of pressure-relieving equipment. All in-patients were assessed using the Waterlow score. Full details of all pressure sores and any pressure-relieving equipment in use was recorded. There was a mean pressure sore prevalence of 7.32%, the prevalence for each survey being 8.77%, 5.1% and 8.1% respectively. Grades 2 and 3 were the most commonly reported grades and the sacrum was the most frequent position. It was anticipated that there would be a difference in dependency between the patient populations in each of the three surveys. This was not so and, when using the Waterlow score, the numbers of patients found to be at no risk, at risk and at high risk remained remarkably stable. Only those in the very high risk category fluctuated. It is postulated that the difference between the prevalence in the three surveys is related to the difference in the numbers of patients seen to be at very high risk. These surveys have provided a basis for selecting pressure-relieving equipment and baseline information for monitoring the efficacy of the prevention programme.     

Paraplegic pressure sore frequency versus circulation measurements

Paraplegic subjects (N = 34) were examined to determine the association of pressure sore history with respect to ankle pressure ratio and buttocks cutaneous plethysmographic harmonic persistence. No relationship was found between pressure sore history and ankle pressure ratio. No significant difference in ankle pressure ratios exists for those who have a pressure sore history as compared to those who have not experienced a pressure sore in 5 years. Those subjects with a diminished buttocks circulation harmonic persistence are more likely to have experienced one or more pressure sores than those subjects with normal circulation characteristics. A Poisson distribution analysis of multiple pressure sore occurrence suggests that repeated pressure sores are unlikely to arise as the result of chance.     

Quantification of pressure relief using interface pressure and tissue perfusion in alternating pressure air mattresses

OBJECTIVE: To examine whether the interface pressure (IP) relief provided by alternating pressure air mattresses (APAMs) is matched with maintenance of tissue perfusion over the points of contact by measuring transcutaneous oxygen and carbon dioxide (tcPO2, tcPCO2). DESIGN: Comparative analysis of 2 APAMs with a 2-parameter continuous time-based method for quantifying pressure relief (PR) and transcutaneous gas measurement for assessing tissue perfusion. SETTING: Rehabilitation research facility in a university hospital. PARTICIPANTS: Eleven able-bodied adult postgraduate student volunteers. MAIN OUTCOME MEASURES: Two full-replacement APAM systems were used. For each mattress the mean maximum and minimum interface pressures; mean peak air pressures in the mattresses; interface pressure durations below 30, 20, and 10 mmHg over a 60-minute period; mean maximum tcPCO2 and minimum tcPO2; and mean area under the tcPO2 and tcPCO2 curves were measured for each subject. RESULTS: IP on the sacrum was held below thresholds of 30, 20, and 10 mmHg longer on a 2-cell, low pressure system than on a 3-cell, high pressure system (p < .001). Integrated over time, tcPO2 levels also indicated that the 2-cell system retained oxygen levels closer to the unloaded baseline than did the 3-cell system (p < .01). tcPCO2 levels did not rise significantly (p > 0.1) compared with the baseline measurement in both mattresses. CONCLUSIONS: PR was sensitive to the design of the APAM, especially its inflation pressure, cycle time, and inflation sequence. If future trials demonstrate that PR values and transcutaneous blood gas measurements correlate significantly with the clinical incidence of pressure sore formation, then this technique may prove useful in assessing the effectiveness of alternating pressure support surfaces.     

Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools.

Patients in intensive care units (ICU) are at high risk of developing pressure sores and the use of pressure sore risk tools has been advocated as a means of identifying patients at risk. A prospective multi-site observational study was conducted to define the incidence of pressure sores, assess two pressure sore risk scales and to define risk factors relevant to intensive care. Patients (n = 534) were assessed for the presence of pressure sores. The Waterlow and Jackson/Cubbin risk scales were completed each day for 314 and 188 of these patients respectively. A total of 75 pressure sores were recorded. Of these, 34 were present on admission. Of the remaining 41, 16 were classified as Grade 1 and 24 as Grade 2 sores. The pressure sore (PS) incidence was 5.2 per cent. Expressed as PS/1000 patient days there were 18.48 pressure sores per 1000 patient days. The ability of the risk scores to predict pressure sores was tested using a Receiver Operating Characteristic (ROC) analysis. The association of risk score with pressure sores was analysed using a survival function (Kaplan Meier) and variables compared using a logrank test (Mantel-Cox). Factors associated with pressure sore occurrence were developed and tested using a survival regression model. Both risk scales were poor predictors of pressure sores (ROC curve area approximately 70 per cent for both). The factors, coma/unresponsiveness/paralysed & sedated and cardiovascular instability were significantly associated with pressure sores with relative risks of 4.2 and 2.5 respectively. Risk increased as a function of time such that the cumulative risk was 50 per cent at 20 days.     

Psychosocial factors associated with pressure sores.

To determine if psychosocial factors, not purely mechanical aspects, play an important part in the incidence of pressure sores, 141 subjects were tested on 3 psychosocial measures. Results indicate that differences exist among groups in pressure sore history and psychosocial measures. Contrary to the expectations of a mechanical skin problem model, quadriplegics as a group (rather than paraplegics) had a history of fewer pressure sores. Two variables, the subject's responsibility in skin care (RESPON) and his satisfaction with the activiities of life (SATIS), were significantly associated with the incidence of decubitus ulcers. The combination of RESPON, SATIS, and the total positive score from the Tennessee Self-Concept Scale in multiple linear regression accounted for (1) 26% of the pressure sore history in the total sample, (2) 40% in the paraplegic group, (3) 69% in the paraplegic with help group, and (4) 41% in the paraplegic without help group. The histories in the quadriplegic groups and subgroups did not show reliable associations with the 3 variables. SATIS contributed most in accounting for the incidence of pressure sores. The level of injury and these psychosocial factors are thus related to the incidence of pressure sores.     

Program for lowering the incidence of pressure sores in neurosurgical patients

Pressure sores are one of the well known problems that occur in hospitals. As the literature on the subject indicates, a lot of money is expended in managing this problem every year, and 12-66% of pressure sores are caused during surgery. Patients who undergo neurosurgical procedures are susceptible to pressure sores because of lengthy operations. We collected data on patients with pressure sores who underwent surgery between May 2004 and August 2004, and found that the incidence of pressure sore in neurosurgical patients was 9.5%, which was the highest among all surgical patients. This project was developed to solve the problem of pressure sores by setting up standard preventive procedures, a nursing follow up system and continuing education courses, and utilizing cotton rolls to pad sites of pressure sores. The incidence of pressure sore in neurosurgical patients was reduced from 9.5% to 7% after the improvement project was carried out. The more concerned nurses are about pressure sores, the better the quality of operative nursing care.     

An investigation into the use of serum albumin in pressure sore prediction

OBJECTIVES: To ascertain the relevance of serum albumin and serum sodium as predictors of pressure sores in addition to the Waterlow score. DESIGN: Observational study of patients at risk of developing decubitus ulcers. SETTING: Staffordshire, in the midlands of the United Kingdom. PARTICIPANTS: 773 elderly hospital in-patients of a district general hospital. MEASUREMENTS: Waterlow scores and serum albumin and sodium. Development of a pressure sore. RESULTS: Logistic regression analysis of serum albumin, serum sodium and the Waterlow score showed the Waterlow score and serum albumin were significant predictors of pressure sores. CONCLUSIONS: Serum albumin may, in this patient group (in-patients over 64 years of age), be a useful predictor of pressure sore occurrence, though further work is needed to establish whether this is the case. Risk assessment of pressure sores can possibly be improved by adding serum albumin to one of the pre-existing tools such as the Waterlow score.     

Intervention studies to reduce the prevalence and incidence of pressure sores: a literature review

Much has been written about the prevention of pressure sores. However, electronic and manual searches located only 10 studies within the literature in the UK that described interventions able to reduce either their incidence or prevalence. All the studies located contained serious methodological flaws. Apparent success in reducing the number or severity of pressure sores could have resulted because staff involved in data collection were aware that the study was being undertaken and thus took more interest in pressure area care. From the review findings it is apparent that there is a dearth of research evidence upon which to base practice in the sphere of pressure sore prevention and further research is urgently required.     

Pressure sore prevalence: a national survey

? A cross-sectional nation-wide sample was used to determine the point prevalence and grading of pressure sores in patients in all hospitals in Iceland (22 hospitals). ? The pressure sore prevalence was 8.9% (n = 57 patients), 7.12% for women (n = 26) and 11.2% for men (n = 31); the mean age for both sexes with pressure sores was 78.4 years. ? Grade I sores were most frequently identified and Grade IV the least. Eighty-five per cent of pressure sores were located below the waist. ? `No dressings' and occlusive dressings were the treatment of choice for pressure sores. ? Results from this study are important for international comparisons.     

Establishing the cost of comfort. Effectiveness of mattresses in pressure sore prevention.

The treatment of pressure sores exerts a significant drain on NHS resources. Identifying mattresses which help to prevent pressure sores can result in substantial long-term savings.