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.     

Independent risk factors for pressure ulcer development in a high‐risk nursing home population receiving evidence‐based pressure ulcer prevention: Results from a study in 26 nursing homes in Belgium

The aim of this study was to identify independent risk factors for pressure ulcer (PU) development in a high‐risk nursing home population receiving evidence‐based PU prevention. This study was part of a randomised controlled trial examining the (cost‐)effectiveness of static air support surfaces compared with alternating pressure air mattresses. The sample consisted of 308 residents at a high risk of PU development (presence of non‐blanchable erythema, Braden score ≤ 12 or Braden subscale “mobility” ≤ 2). PU incidence was monitored for 14 days. Demographic variables; functional, physical, and psychological characteristics; and data on skin assessment were collected. Independent risk factors were identified using multiple logistic regression analysis. The overall PU incidence (category II‐IV) was 8.4% (n = 26), and 1.9% (n = 6) of the residents developed a deep PU (category III‐IV). PUs (category II‐IV) were significantly associated with non‐blanchable erythema, a lower Braden score, and pressure area‐related pain in high‐risk residents even if preventive care was provided. These results highlight the need of a systematic risk assessment, including pain assessment and skin observations, in order to determine and tailor preventive care to the needs of high‐risk individuals.     

The effect of Web-based Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments.

OBJECTIVE: To evaluate the effect of Web-based Braden Scale training on the reliability and precision of pressure ulcer risk assessments made by registered nurses (RN) working in acute care settings. DESIGN: Pretest-posttest, 2-group, quasi-experimental design. SETTING AND SUBJECTS: Five hundred Braden Scale risk assessments were made on 102 acute care patients deemed to be at various levels of risk for pressure ulceration. Assessments were made by RNs working in acute care hospitals at 3 different medical centers where the Braden Scale was in regular daily use (2 medical centers) or new to the setting (1 medical center). INSTRUMENT: The Braden Scale for Predicting Pressure Sore Risk was used to guide pressure ulcer risk assessments. A Web-based version of the Detroit Medical Center Braden Scale Computerized Training Module was used to teach nurses correct use of the Braden Scale and selection of risk-based pressure ulcer prevention interventions. RESULTS: In the aggregate, RN generated reliable Braden Scale pressure ulcer risk assessments 65% of the time after training. The effect of Web-based Braden Scale training on reliability and precision of assessments varied according to familiarity with the scale. With training, new users of the scale made reliable assessments 84% of the time and significantly improved precision of their assessments. The reliability and precision of Braden Scale risk assessments made by its regular users was unaffected by training. CONCLUSION: Technology-assisted Braden Scale training improved both reliability and precision of risk assessments made by new users of the scale, but had virtually no effect on the reliability or precision of risk assessments made by regular users of the instrument. Further research is needed to determine best approaches for improving reliability and precision of Braden Scale assessments made by its regular users.     

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.     

Effectiveness on hospital‐acquired pressure ulcers prevention: a systematic review

The effective approach on pressure ulcer (PU) prevention regarding patient safety in the hospital context was evaluated. Studies were identified from searches in EBSCO host, PubMed, and WebofScience databases from 2009 up to December 2018. Studies were selected if they were published in English, French, Portuguese, or Spanish; incidence of PUs was the primary outcome; participants were adults (≥18 years) admitted in hospital wards and/or units. The review included 26 studies. Studies related to prophylactic dressings applied in the sacrum, trochanters, and/or heels, education for health care professionals, and preventive skin care and system reminders on‐screen inpatient care plan were effective in decreasing PUs. Most of the studies related to multiple intervention programmes were effective in decreasing PU occurrence. Single interventions, namely support surfaces and repositioning, were not always effective in preventing PUs. Repositioning only was effective when supported by technological pressure‐mapping feedback or by a patient positioning system. Risk‐assessment tools are not effective in preventing PUs. PUs in the hospital context are still a worldwide issue related to patient safety. Multiple intervention programmes were more effective in decreasing PU occurrence than single interventions in isolation. Single interventions (prophylactic dressings, support surfaces, repositioning, preventive skin care, system reminders, and education for health care professionals) were effective in decreasing PUs, which was always in compliance with other preventive measures. These results provide an overview of effective approaches that should be considered when establishing evidence‐based guidelines to hospital health care professionals and administrators for clinical practice effective in preventing PUs.     

Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans

This study sought to determine if a parsimonious pressure ulcer (PU) predictive model could be identified specific to acute care to enhance the current PU risk assessment tool (Braden Scale) utilized within veteran facilities. Factors investigated include: diagnosis of gangrene, anemia, diabetes, malnutrition, osteomyelitis, pneumonia/pneumonitis, septicemia, candidiasis, bacterial skin infection, device/implant/graft complications, urinary tract infection, paralysis, senility, respiratory failure, acute renal failure, cerebrovascular accident, or congestive heart failure during hospitalization; patient's age, race, smoking status, history of previous PU, surgery, hours in surgery; length of hospitalization, and intensive care unit days. Retrospective chart review and logistic regression analyses were used to examine Braden scores and other risk factors in 213 acutely ill veterans in North Florida with (n = 100) and without (n = 113) incident PU from January–July 2008. Findings indicate four medical factors (malnutrition, pneumonia/pneumonitis, candidiasis, and surgery) have stronger predictive value (sensitivity 83%, specificity 72%, area under receiver operating characteristic [ROC] curve 0.82) for predicting PUs in acutely ill veterans than Braden Scale total scores alone (sensitivity 65%, specificity 70%, area under ROC curve 0.70). In addition, accounting for four medical factors plus two Braden subscores (activity and friction) demonstrates better overall model performance (sensitivity 80%, specificity 76%, area under ROC curve 0.88).     

Point prevalence of pressure ulcers in three second‐level hospitals in Mexico

Pressure ulcers (PU) are the source of multiple complications and even death. To our knowledge, there is no available data about PU prevalence in Mexico. The objective of this study was to determine the point prevalence of PU in three second‐level hospitals in Mexico. Every adult hospitalised patient was included in each hospital. Age, gender, hospitalisation ward, Braden score, and the number, location and stage of the ulcers encountered were recorded, as well as any pressure relief measures. In total, 294 patients were examined (127 were male); of these, 63 were considered to be at risk. The average age was 48·6 years. The overall prevalence of the PU was 17%. The service with the highest prevalence was the ICU. The most frequent stage was II (32%) and they were most commonly found in the sacrum (74%). The average Braden score of the patients with ulcers was 10, and 21·4% of the patients obtained moderate‐ to high‐risk Braden scores. Of them, 60·3% had ulcers and only 46% had any preventive measures. The prevalence of PU in three hospitals in Mexico is 17%. The most common stage is II and the most commonly affected site is the sacrum. Only 46% of patients with PU had at least one pressure release measure.     

Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers.

OBJECTIVE: We sought to determine whether identification of comorbidities (in addition to daily Braden scale assessment and early aggressive pressure reduction interventions) would impact the development of facility-acquired pressure ulcers (FAPU) of the heel. METHODS: Patients admitted to a 333-bed community hospital located 20 miles west of Chicago. Overall, 70 medical records were reviewed, while 242 adult patients (46 in the intervention groups and 196 in the control groups) and 24 nurses participated in the study. The study was conducted in 4 phases, including a retrospective chart audit, 2 prospective interventions, and a product evaluation. Phase 1 entailed a retrospective chart review of patients who were admitted with or developed heel pressure ulcers over a 2-year period to identify factors most predictive of skin breakdowns. Phase 2 included two 10-day aggressive assessment and tailored intervention periods. Phase 3 involved prevalence day assessments of effectiveness of interventions as compared to patients on control nursing units. Phase 4 involved a staff survey comparing effectiveness and satisfaction of the current and trial heel pressure-relieving products. FINDINGS: Risk factors for development of heel ulcers during hospital stay or prior to admission included type 2 diabetes mellitus (T2DM), peripheral vascular disease (PVD), low albumin, and Braden scale score. During implementation of phase 2 (two 10-day assessment and tailored intervention periods), no heel FAPU were associated with the intervention. During the phase 3 FAPU prevalence assessment, 3 patients had facility-acquired heel ulcers; 2 were in the control group and would have met inclusion criteria if included in the intervention. One patient was in the intervention group but was not following the protocol. During phase 4, there were significant preferences for the trial heel pressure relief device on effectiveness, as well as patient and staff satisfaction. CONCLUSION: A pressure ulcer prevention protocol that incorporated accurate assessment of risk factors (Braden Scale and comorbidities) with frequent documentation of heel skin integrity had a positive impact on the incidence of heel FAPU. In addition, early aggressive implementation of pressure-reducing and pressure-relieving devices was effective in reducing FAPU rates.     

Using the Braden subscales to assess risk of pressure injuries in adult patients: A retrospective case‐control study

The aim of this study was to compare the pressure injury risk predictability between the individual Braden subscales and the total Braden scale in adult inpatients in Singapore. A retrospective 1:1 case‐control design was used from a sample of 199 patient medical records. Clinical data were collected from a local university hospital's medical records database. The results showed that, among the six subscales, the activity subscale was the most sensitive and specific in predicting pressure injury (PI). However, the overall results showed that the Braden scale remained the most predictive of PI development in comparison with the individual subscales. The study also found that, among the Singaporean patients, the Braden cut‐off score for PI risk was 17 compared with the current cut‐off score of 18. Therefore, it may be relevant for local tertiary hospitals to review their respective Braden cut‐off scores as the study results indicate an over‐prediction of PI risk, which leads to unnecessary utilisation of resources. The hospital may also consider developing a PI prevention bundle comprising commonly used preventive interventions when at least one Braden subscale reflects a suboptimal score.     

Prevention of nosocomial pressure ulcers: a process improvement project.

Nosocomial pressure ulcers (PU) occur in approximately 12% of all hospitalized patients. The risk can be determined by a variety of intrinsic and extrinsic factors. As a first line of defense against nosocomial PU, we use the Braden Scale to determine the potential risk of PU development during hospitalization. Once risk was identified, our standard was to implement an individualized plan of care. However, consistent implementation of PU preventative measures was lacking. As a result, a process improvement project was developed and implemented. The purpose of this process improvement project was to increase communication about and awareness of the need to vigorously intervene and document whenever there is risk of, or development of, a nosocomial PU. By initiating consistent use of a PU Tracking Form, developing unit-based wound champions that serve as experts in ulcer prevention, and creating an individual case analysis process, PU prevention and tracking was institutionalized. Results indicate that our nosocomial PU rate has declined from 7% to 4%.     

Practice versus knowledge when it comes to pressure ulcer prevention

Purpose: This study was completed to determine the current knowledge and documentation patterns of nursing staff in the prevention of pressure ulcers and to identify the prevalence of pressure ulcers.Methods: This pre-post intervention study was carried out in three phases. In phase I, 67 nursing staff members completed a modified version of Bostrom's Patient Skin integrity Survey. A Braden Scale score, the presence of actual skin breakdown, and the presence of nursing documentation were collected for each patient (n = 43). Phase II consisted of a 20-minute educational session to all staff. In phase III, 51 nursing staff completed a second questionnaire similar to that completed in phase I. Patient data (n = 49) were again collected using the same procedure as phase I.Results: Twenty-seven staff members completed questionnaires in both phase I and phase III of the study. No statistically significant differences were found in the knowledge of the staff before or after the educational session. The number of patients with a documented plan of care showed a statistically significant difference from phase I to phase III. The number of patients with pressure ulcers or at risk for pressure ulcer development (determined by a Braden Scale score of 16 or less) did not differ statistically from phase I to phase III.Conclusion: Knowledge about pressure ulcers in this sample of staff nurses was for the most part current and consistent with the recommendations in the Agency for Health Care Policy and Research guideline. Documentation of pressure ulcer prevention and treatment improved after the educational session. Although a significant change was noted in documentation, it is unclear whether it reflected an actual change in practice.     

Stress-inducing factors in ICUs: what liver transplant recipients experience and what caregivers perceive.

The aim of this study was to compare a number of potentially stress-generating factors related to an intensive care unit (ICU) stay from the points of view of patients undergoing liver transplantation or elective major abdominal surgery and their caregivers in order to identify differences and similarities that may help to optimize patient care. The ICU Environmental Stressor Scale questionnaire was administered to 104 liver transplant recipients, 103 major abdominal surgery patients, 35 nurses and 21 physicians. The ICU staff were asked to complete the questionnaire on the basis of their perception of patient stressors. Both patient groups identified Being unable to sleep, Being in pain, Having tubes in nose/mouth, Missing husband/wife, and Seeing family and friends only a few minutes a day as the major stressors; the healthcare providers correctly identified the most stressing factors for the patients, but gave them higher scores. The mean scores were 71.9 +/- 18.7 for the transplant recipients, 66.3 +/- 20.9 for the patients undergoing elective major abdominal surgery, 99.7 +/- 19.2 for the nurses, and 92.7 +/- 16.1 for the physicians (P < 0.001). The qualitative evaluations of potentially stress-inducing ICU situations were substantially the same in the 2 patient groups, but the transplant recipients seemed to feel them more acutely. Although the caregivers identified the most discomforting situations, they overestimated the degree of stress they cause. The staff of each ICU should therefore seek to understand and reduce (even by means of simple interventions) the particular causes of psychophysical stress felt by their patients.     

Relationship between Braden scale score and pressure ulcer development in patients admitted in trauma intensive care unit

The purpose of this study was to determine the relationship between the scores of Braden scale and pressure ulcer development among critically ill patients. All patients who admitted to intensive care unit (ICU) in 3 months (during July-October 2010) were surveyed with Braden scale. Patients who gained higher score of Braden scale were at lower risk for pressure ulcer development compared with the other patients. Braden scale is a useful tool for predicting pressure ulcer development in trauma ICU patients. Also, factors such as age and level of consciousness may influence pressure ulcer development.     

Consistent pressure ulcer prevention practice: The effect on PU prevalence and PU stages,and impact on PU prevention—A quasi-experimental intervention study

This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for residents. A quasi-experimental intervention study was conducted. The data were collected from 232 residents (n = 115 in intervention and 117 in comparison group) in two public long-term older people care (LOPC) facilities in Finland using the Pressure Ulcer Patient instrument (PUP-Instrument). The facilities were chosen with convenience sampling, after which they were randomly allocated as either intervention or comparison facility. Based on international guidelines for PU prevention, the renewed, consistent PU prevention practice with six areas was developed and implemented using the operational model for evidence-based practices (OMEBP). After the intervention, a significant difference between the intervention and the comparison facility was seen in the prevalence of PUs and in the residents’ highest stage of PUs in the sacrum, buttock and hip areas, and heels. Between the facilities, a significant difference was seen in the use of PU and nutrition risk assessment instruments and nutritional supplements, time used for repositioning in the daytime and at night-time, lifting belt use, and avoiding shearing or stretching residents’ skin. The successful intervention improved skin integrity in LOPC facilities.     

Inter‐rater reliability of three most commonly used pressure ulcer risk assessment scales in clinical practice

The objective of this study was to evaluate inter‐rater reliability of Braden Scale, Norton Scale and Waterlow Scale for pressure ulcer risk assessment in clinical practice. The design of the study was cross‐sectional. A total of 23 patients at pressure ulcer risk were included in the study, and 6 best registered nurses conducted three subsequent risk assessments for all included patients. They assessed alone and independently from each other. An intra‐class correlation coefficient (ICC) was used to determine the inter‐rater reliability. For the Braden Scale, the ICC values ranged between 0·603 (95% CI: 0·435–0·770) for the item ‘moisture’ and a maximum of 0·964 (95% CI: 0·936–0·982) for the item ‘activity’; for the Norton Scale, the ICC values ranged between 0·595 (95% CI: 0·426–0·764) for the item ‘physical condition’ and a maximum of 0·975 (95% CI: 0·955–0·988) for the item ‘activity’; and for the Waterlow Scale, the ICC values ranged between 0·592 (95% CI: 0·422–0·762) for the item ‘skin type’ and a maximum of 0·990 (95% CI: 0·982–0·995) for the item ‘activity’. The ICC values of total score for three scales of were 0·955 (95% CI: 0·922–0·978), 0·967 (95% CI: 0·943–0·984), and 0·915 (95% CI: 0·855–0·958) for Braden, Norton, and Waterlow scales, respectively. Although the inter‐rater reliability of Braden Scale, Norton Scale and Waterlow Scale total scores were all substantial, the reliability of some items was not so good. The items of ‘moisture’, ‘physical condition’ and ‘skin type’ should be paid more attention. However, some studies are needed to find out high reliable quantitative items to replace these ambiguous items in new designed scales.     

The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program

Objectives

To implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks.

Design

Quality improvement.

Setting

SCI Rehabilitation Center.

Participants

Inpatients admitted January 2012 to July 2013.

Interventions

Implementation of two PU best practices were targeted: (1) completing a comprehensive PU risk assessment and individualized interprofessional PU prevention plan (PUPP); and (2) providing patient education for PU prevention; as part of the pan-Canadian SCI Knowledge Mobilization Network. At our center, the SCI Pressure Ulcer Scale replaced the Braden risk assessment scale and an interprofessional PUPP form was implemented. Comprehensive educational programing existed, so efforts focused on improving documentation. Implementation science frameworks provided structure for a systematic approach to best practice implementation (BPI): (1) site implementation team, (2) implementation drivers, (3) stages of implementation, and (4) improvement cycles. Strategies were developed to address key implementation drivers (staff competency, organizational supports, and leadership) through the four stages of implementation: exploration, installation, initial implementation, and full implementation. Improvement cycles were used to address BPI challenges.

Outcome Measures

Implementation processes (e.g. staff training) and BPI outcomes (completion rates).

Results

Following BPI, risk assessment completion rates improved from 29 to 82%. The PUPP completion rate was 89%. PU education was documented for 45% of patients (vs. 21% pre-implementation).

Conclusion

Implementation science provided a framework and effective tools for successful pressure ulcer BPI in SCI rehabilitation. Ongoing improvement cycles will target timeliness of tool completion and documentation of patient education.     

Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving home health care.

PURPOSE: The purpose of this study was to determine whether certain Braden subscales or subscores were more important than others or the summative score in predicting stage I to IV pressure ulcers among older adults receiving home health care. DESIGN: A retrospective cohort study (secondary analysis) was used. SETTING AND SUBJECTS: The cohort sample included 1684 nonhospice patients who were not receiving intravenous therapy and who were admitted to the Intermittent Skilled Nursing Division of a large midwestern home health care agency between January 1995 and March 1996. The patients were > or =60 years and free of pressure ulcers. METHODS: Demographic data and data on the Braden Scale were extracted from admission information. Patient records were followed forward chronologically to 1 of 2 outcomes: development or absence of pressure ulcers (ie, free of pressure ulcers upon discharge, institutionalization, death, or the end of the study period). RESULTS: Following admission, a stage I to IV pressure ulcer developed in 107 subjects (incidence = 6.3%). Cox regression analysis revealed that activity and moisture subscale scores predicted pressure ulcer development. Regression modeling of individual Braden Scale subscores (response categories) revealed that problems with friction/shear, being very limited in mobility, and being constantly moist, very moist, or occasionally moist predicted pressure ulcer development. When the overall level of risk was added to each of these models, the Braden Scale summative score was most strongly related to pressure ulcer development. No simplified scale improved risk prediction. CONCLUSIONS: When the Braden Scale was used, the summative score rather than any subscale or subscore best predicted pressure ulcer risk among the older adults receiving home health care.