Hospital pressure ulcer prevalence rates and number of raters

Aim. The purpose of this study was to evaluate the influence of different numbers of nurse raters conducting skin inspection (one or two) on observed pressure ulcer prevalence rates. Background. Pressure ulcer prevalence and incidence rates are important outcome measures for the quality of care. To ensure reliability and comparability of such rates standardisation of study methods is recommended. It is assumed that data accuracy can be improved if skin inspection is conducted by a team of two raters. Design. A secondary data analysis of pressure ulcer prevalence data was conducted. Method. Groups of hospital patients which were examined by one (n = 2420) or two raters (n = 15,009) were compared regarding demographic characteristics, pressure ulcer risk and pressure ulcer prevalence. Logistic regressions were conducted to examine the association between the number of raters (one or two) and the outcome pressure ulcer (yes/no). Results. Groups of one and two raters were comparable regarding demographic characteristics. There was no statistically significant difference regarding pressure ulcer prevalence between both groups (p = 0·222). There was no relation between the number of raters and the probability of identifying a pressure ulcer patient (p = 0·060). Conclusions. Pressure ulcer prevalence rates in the analysed studies were not affected by the number of raters. There seems to be no relation between the numbers of nurses conducting skin inspection and observed prevalence rates. Relevance to clinical practice. Conducting pressure ulcer prevalence studies require a lot of effort and personal costs. Provided that one nurse alone or a team of two nurses rate the existence of pressure ulcers equally it is no longer obligatory to have two raters. This would save resources. However, when patients are restricted in their mobility two nurses are recommended to provide assistance in patient turning.     

Development of a neonatal case-mix classification

This article introduces a neonatal classification based on latent class analysis. The neonatal classification generates five distinct classes ranging from the normal-birth-weight, full-term, healthy baby to the low-birth-weight preterm infant with many life-threatening problems. Unlike several suggested neonatal classifications, latent class analysis accommodates the range and severity of illness typically encountered in neonatal populations. It also provides a classification based solely on the personal characteristics of the newborn that can be used to investigate variation in the use of neonatal services.     

持续压疮管理改进措施对降低压疮患病率的效果研究

压疮是重要的病人安全问题.采取有效措施减少压疮发生是护理管理的重要内容和目标.压疮患病率是监测压疮管理效果的科学指标[1].我院借鉴国外的管理经验,于2009年4月进行了首次压疮患病率调查,在此基础上对压疮管理制度进行了修订并实施,于2009年10月再次进行压疮患病率调查,现将结果报道如下.     

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.     

ICU project to improve pressure ulcer healing rates

Pressure ulcers represent a very common complication in elderly and patients receiving bedridden care. Inappropriate management of this condition can lead to delayed healing, serious infections and even mortality. The rate of healing for pressure ulcers in our department was 0% between January and June, 2003. We studied this situation and identified the following problems: (1) improper diagnoses; (2) failure to implement a pressure ulcer care protocol; (3) lack of proper instruments to reduce pressure; and (4) failure to care properly for skin following excretion. Nursing knowledge and practice were not updated with new concepts and methods related to clinical pressure ulcer care. To solve these problems and improve pressure ulcer care effectiveness, we organized a special unit in July of the same year, which proceeded to arrange lectures and promotional campaigns, published a standardized care protocol, designed water cushions, and established proper post-excretion care procedures. According to observed results, our department improved its pressure ulcer healing rate by 41.2% within 6 months. This project improved skin care quality and reduced pressure ulcer complications. We recommend that findings and measures be promoted in clinical practice.     

住院患者压疮患病率研究进展

压疮是局部组织长时间受压,血液循环障碍,局部持续缺血、缺氧、营养不良而导致的软组织溃疡和坏死。它是影响患者舒适和安全的一个重要问题。压疮的预防和干预管理越来越受到重视。用科学的方法对压疮发生的情况进行监控,是压疮管理的基础,并且是监测压疮管理效果的依据。世界上很多国家对压疮患病率进行了研究,我国刚刚起步。现将压疮患病率研究现状进行总结,为我国加强该方面的研究和管理提供借鉴。     

Effect of non-response bias in pressure ulcer prevalence studies

AIM: This paper reports a study to determine the prevalence of pressure ulcers in German hospitals and nursing homes for national and international comparison, and analyses the influence of non-response bias. BACKGROUND: Outcome rates are often used to evaluate provider performance. The prevalence of pressure ulcers is seen as a possible parameter of outcome healthcare quality. However, the results from different pressure ulcer prevalence studies cannot be compared, because there is no standardized methodology and terminology. Observed and published prevalence rates may reflect variations in quality of care, but differences could also relate to differences in case-mix or to random variation. METHODS: A point prevalence survey was carried out for 2002 and 2003 using data from 21,574 patients and residents in 147 different kinds of institutions throughout Germany. Participation rates and reasons for not participating in the study were documented. Non-responders were considered in different calculations to show the range of possible prevalence rate for a hypothetic 100% participation. RESULTS: In 2002 and 2003, the calculated prevalence rate (among participating persons at risk) in hospitals was 25.1% and 24.2% respectively, while in nursing homes it was 17.3% and 12.5% respectively. Non-response varied from 15.1% to 25.1%. The majority of non-responders in hospitals and nursing homes had not been willing to participate in the study. Based on different assumptions about the characteristics of the non-responders, we calculated minimum and maximum prevalence rates as if 100% participation was achieved. CONCLUSIONS: Calculating the non-response bias of prevalence rates is an inconvenient but necessary thing to do because its influence on calculated prevalence rates was high in this study. High participation rates in clinical studies will minimize non-response bias. If non-response cannot be avoided, the formula provided will help researchers calculate possible minimum and maximum prevalence rates for the total sample of both the responding and non-responding groups.     

Development and validation of a psychiatric case-mix system

BACKGROUND: Although difficulties in applying risk-adjustment measures to mental health populations are increasingly evident, a model designed specifically for patients with psychiatric disorders has never been developed. OBJECTIVE: Our objective was to develop and validate a case-mix classification system, the "PsyCMS," for predicting concurrent and future mental health (MH) and substance abuse (SA) healthcare costs and utilization. SUBJECTS: Subjects included 914,225 veterans who used Veterans Administration (VA) healthcare services during fiscal year 1999 (FY99) with any MH/SA diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 290.00-312.99, 316.00-316.99). METHODS: We derived diagnostic categories from ICD-CM codes using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions, clinical input, and empiric analyses. Weighted least-squares regression models were developed for concurrent (FY99) and prospective (FY00) MH/SA costs and utilization. We compared the predictive ability of the PsyCMS with several case-mix systems, including adjusted clinical groups, diagnostic cost groups, and the chronic illness and disability payment system. Model performance was evaluated using R-squares and mean absolute prediction errors (MAPEs). RESULTS: Patients with MH/SA diagnoses comprised 29.6% of individuals seen in the VA during FY99. The PsyCMS accounted for a distinct proportion of the variance in concurrent and prospective MH/SA costs (R=0.11 and 0.06, respectively), outpatient MH/SA utilization (R=0.25 and 0.07), and inpatient MH/SA utilization (R=0.13 and 0.05). The PsyCMS performed better than other case-mix systems examined with slightly higher R-squares and lower MAPEs. CONCLUSIONS: The PsyCMS has clinically meaningful categories, demonstrates good predictive ability for modeling concurrent and prospective MH/SA costs and utilization, and thus represents a useful method for predicting mental health costs and utilization.     

压疮护理SD大鼠模型的建立

目的建立适于研究压疮预防护理的动物模型。方法健康雄性SD大鼠30只,随机分为6组,每组5只,麻醉后使其仰卧于设计好的简易加压装置,以大鼠后肢关节为压迫点,每组的压力大小分别为70,64,58,53,48,44mmHg,持续作用2h后,观察受压部位皮肤的外观改变,并应用寇氏法（Karbar氏法）计算使半数动物受压部位皮肤发红的压强。结果各组均未出现肉眼可见的皮肤破损等严重变化,但受压局部皮肤肉眼观察可见发红现象。在此实验条件下,使半数动物皮肤发红的压强大小为55．08mmHg。结论在此装置下,建立这个模型最合适的压强应为55．08mmHg。以此压强建立的SD大鼠动物模型方法简单易行,可应用于预防压疮护理的动物实验研究。     

Development of pressure ulcer program across a university health system

Pressure ulcers were designated as a priority for quality care initiatives at the University of Pennsylvania Health System. The Penn Medicine Pressure Ulcer Collaborative was developed to address the complex issues of pressure ulcers. The Collaborative used a systematic approach to analyze, plan, and implement a health system-wide pressure ulcer program. As a result, the entire health system had a decrease in hospital-acquired pressure ulcer prevalence rates of 37%. This article describes the Collaborative's innovative approach to quality improvement.     

Does the number of raters influence the pressure ulcer prevalence rate?

We analyzed data from pressure ulcer prevalence studies conducted in nursing homes between 2004 and 2006 concerning differences in the observed pressure ulcer prevalence rates while looking into the number of nurses conducting skin inspections (one or two). Results of the analysis revealed that the number of raters did not influence the observed pressure ulcer prevalence rate. Adequate preparation and training of ward nurses for data collection seem to be sufficient to achieve reliable data.     

Development and application of a population-oriented measure of ambulatory care case-mix

This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.     

Nosocomial pressure ulcer rates in critical care: performance improvement project

Assessment, monitoring, and prevention of pressure ulcers in the hospitalized patient are required standards of care. The annual nosocomial pressure ulcer (NPU) rates for the adult intensive care units at our facility had trended up to 33% from 14% over a 13-month period. Our performance improvement team decided to track 5 variables that may have contributed to the increased incidence of NPU. Weekly skin care rounds were conducted to collect data, educate staff, and reinforce skin care policy and standards of care. Data analysis revealed 3 areas that required further emphasis with nursing staff: daily assessment with the Braden Scale, prevention of NPU beginning on the day of hospital admission, and the effect of sedation on patient mobility. Implementation of appropriate interventions targeted to specific Braden subscales needs to be included in the plan of care.