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.     

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.     

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.     

Improving the quality of pressure ulcer management in a skilled nursing facility

Pressure ulcers (PUs) are a serious health care problem for nursing home residents and a key quality metric for regulators. Three initiatives were introduced at a 128‐bed facility to improve PU prevention. First, a Quality Assurance and Performance Improvement project and a Root Cause Analysis were conducted to improve the facility's wound care programme. Second, a digital wound care management solution was adopted to track wound management. Third, the role of skin integrity coordinator was created as a central point of accountability for wound care‐related activities and related performance metrics. Improvements in PU prevention were tracked using Centers of Medicare and Medicaid data, specifically (a) the percentage of long‐stay high‐risk residents with PUs and (b) the percentage of short‐stay residents with PUs that are new or have worsened. PU prevalence for long‐stay high‐risk residents was 12.99% (Q4 2016), and upon implementation of these initiatives, the facility saw continued reductions in PU prevalence to 2.9% (Q4 2017), while PUs for short‐stay residents were maintained at zero throughout this period. This study highlights the power of effective management combined with real‐time data analytics, as enabled by digital wound care management, to make significant improvements in health care delivery.     

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.     

Pressure ulcer Cat. II‐IV incidence on the CuroCell S.A.M. PRO powered reactive air support surface in a high‐risk population: A multicentre cohort study in 12 Belgian nursing homes

The primary objective was to study pressure ulcer (PU) category II‐IV (including suspected deep tissue injury and unstageable PUs) cumulative incidence and PU incidence density, in a 30day observation period, associated with the use of the CuroCell S.A.M. PRO powered reactive air support surface in nursing home residents at risk for PU development. Secondary objectives were to study (a) PU category I cumulative incidence and PU incidence density and (b) user (caregivers and residents) experiences and perceptions of comfort associated with the use of the support surface under study. A multicentre cohort study was set up in 37 care units of 12 Belgian nursing homes. The sample consisted of 191 residents at risk of PU development (Braden score ≤ 17). The cumulative PU incidence was 4.7% (n = 9). The PU incidence density was 1.7/1000 observation days (9 PU/5370 days). The experience and perceptions of comfort analysis revealed that the CuroCell S.A.M. PRO powered reactive air support surface was comfortable for daily use. The mode of action and the quietness of the pump function had a positive impact on sleep quality. Patient comfort and sleep quality are essential criteria in the selection of a support surface.     

基于Logistic回归分析的风险评估对医院感染的预防作用

目的探讨基于Logistic回归分析的风险评估对医院感染的预防作用。 方法回顾性分析本院2008年1月至2014年12月武汉科技大学附属孝感市中心医院1 626例住院患者的临床资料,根据患者住院期间是否发生医院感染分为感染组（520例）和对照组（1 106例）。通过Logistic回归分析确定医院感染危险因素并形成风险评估量表,对2015年1月至2016年2月收治的352例住院患者进行医院感染风险评估。 结果住院时间> 15 d、使用三联抗菌药物、使用呼吸机、留置导尿管、全身麻醉、合并肝病、合并血液性疾病、合并糖尿病、激素治疗、放疗或化疗、手术时间> 3 h以及侵入性操作均为医院感染的独立危险因素（P均< 0.05）。建立风险评估量表后医院感染发生率为25.00%,低于评估量表建立前的31.98%（χ² = 6.622,P < 0.05）。 结论基于Logistic回归分析的风险评估模型可有效评估患者感染风险,为医院感染的预防提供依据,并可有效降低医院感染风险。     

基于JCI标准的医院压疮现患率和院内压疮发生率调查

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

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.     

Consistent practices in pressure ulcer prevention based on international care guidelines: A cross‐sectional study

The use of consistent and evidence‐based practices is essential in terms of patient safety and quality of care. The purpose of this study was to describe the use of consistent practices in PU prevention based on international care guidelines and to assess the validity and reliability of the pressure ulcer prevention practice (PUPreP) instrument. The data (n = 554) were collected between 2018 and 2019 from nursing professionals working at two hospital districts in Finland using the PUPreP instrument. The instrument consisted of 42 items assessing participants'' perceptions of the frequencies of pressure ulcer prevention practices with the following scale: never, sometimes, often, always. The data were analysed using statistical analysis. According to the results, the use of pressure ulcer prevention practices was more frequently described as often. The most frequently used prevention practice was repositioning, and the least frequently used practice was nutrition. Factors related to nursing professionals'' pressure ulcer prevention practices were the working sector, education and working frequency in pressure ulcer prevention, and early identification of pressure ulcers. The study results suggest that the evidence‐based pressure ulcer prevention practices were followed at a moderate level by nurses. The PuPreP instrument demonstrated validity and reliability, but further development is needed.     

新生儿重症监护病房医院感染的危险因素分析

目的：通过对新生儿重症监护病房医院感染病例的危险因素进行回顾性分析,为预防和控制新生儿医院感染提供科学依据。方法收集本院新生儿重症监护病房2008年1月至2012年6月收治的1186例患儿资料,对确诊为院内感染患儿的流行病学资料、住院期间的临床资料及实验室相关检测结果进行回顾性分析。结果1186例新生儿患者中有85例患儿存在医院感染,医院感染发生率为7.17%;病原菌以革兰阴性菌最多见（53/85,62.4%）,主要为肺炎克雷伯菌（18/85,21.2%）、鲍曼不动杆菌（12/85,14.1%）、铜绿假单胞菌（7/85,8.2%）和大肠埃希菌（5/85,5.9%）。本组病例院内感染的临床表现以肺炎（35/85,41.2%）最为常见,其中呼吸机相关性肺炎占所有肺炎的68.6%（24/35）;其次为败血症（22/85,25.9%）和腹泻（12/85,14.1%）。多元Logistic回归分析结果显示,机械通气（OR=1.921）、脐静脉置管（OR=1.301）、住院时间（OR=1.076）、胎龄（OR=1.125）和胎膜早破（OR=1.207）等是新生儿发生院内感染的主要危险因素。结论新生儿院内感染的病原菌以革兰阴性菌为主;缩短机械通气和住院时间,尽早拔除静脉置管可降低新生儿院内感染发病率。     

Improving hand hygiene in a low‐resource setting: A nurse‐led quality improvement project

Hand hygiene is a simple but often ignored practice in health care systems worldwide, but it is integral for nosocomial infection prevention, with many hospital‐acquired infections being linked to inadequate hand hygiene practice. At the burns unit in Kamuzu Central Hospital, 50% of patients were found to have acquired pseudomonas infections: one of the contributing factors being inadequate hand hygiene. This quality improvement project was part of a course for nurses to introduce change for patient benefit, with the aim of increasing the baseline figures for hand hygiene practices and hand hygiene facilities from 37% and 22%, respectively (baseline collected in November 2019). Using robust, standard quality improvement processes, measures were put in place such as checklists to observe hand hygiene compliance and facilities, appointment of a hand hygiene committee who monitored and sustained activities of the project, procurement and distribution of handrub and placement of hand‐washing buckets and soap at strategic points. The project saw an increase in availability of hand‐washing facilities to 95.6% and hand hygiene practices increase to >80% within 6 months. The project demonstrates that low cost interventions, led by nurses, can make a real difference to practice in resource poor countries.     

Sub epidermal moisture measurement and targeted SSKIN bundle interventions,a winning combination for the treatment of early pressure ulcer development

This study aimed to investigate the impact of sub epidermal moisture (SEM) measurement and targeted pressure ulcer (PU) prevention, versus visual skin assessment and usual care, on mean SEM delta scores and early pressure ulcer development in acute hospital patients. A quantitative quasi-experimental observational approach was used. A total of 149 at risk acute hospital patients took part, 78 treatment, and 71 control. SEM deltas were recorded daily for a maximum of 5 days using the SEM Scanner (Bruin Biometrics LLC, Los Angeles, California), on three sites: the sacrum, the right heel, and the left heel, with enhanced and targeted PU prevention interventions occurring in those with an elevated SEM delta scores in the treatment group. Intention to treat analysis was used to guide the final composition of results. SEM PU represents PU development as identified by 2 days of sustained abnormal SEM delta scores, ≥0.5, after day one. The mean number of days completed by participants was just under 4 days, participants had many different comorbidities, with the most common being: hypertension, cancer, and chronic obstructive pulmonary disease. Results showed that following the introduction of SEM guided targeted treatments, participants in the treatment group yielded a statistically significant reduction in mean SEM delta scores (MD: 0.49; 95% CI: 0.59, 0.39; P < .0001), and in the odds of developing a SEM PU (OR: 0.59, 95% CI: 0.24 to 1.00; P = .05). In the treatment group, none of the participants developed a visual PU, whereas, in the control group, 1.41% (n = 1/71) developed a visual PU. Based on all the results, the following is concluded, (1). There was a greater reduction in mean SEM delta scores among those cared for using SEM measurement and targeted PU prevention, versus those cared for using visual skin assessment and usual care, and (2). the mean SEM delta scores was statistically significantly lower at the study end for those who received targeted treatments based on abnormal SEM scores. More research is now needed in other and larger at-risk groups to further validate what was found in this study.     

基于关联规则的医院感染数据挖掘

目的:探讨关联规则挖掘在医院感染诊断中的应用研究。方法:采用关联规则挖掘算法FP-growth算法,通过设置最小支持度和最小可信度对医院感染病例进行关联分析。结果:从解放军总医院第一附属医院提取400例患者的相关数据,设置最小支持度和最小置信度分别为10%和50%,得到关联规则13条,揭示了年龄、是否有介入操作、抗生素使用、住院时间等因素与医院感染的发生和诊断之间有关联关系。结论:在医院感染病例中挖掘关联规则可以发现医院感染与其产生的可能因素间的规则,这些规则为医院感染的诊断和预防提供重要参考依据。     

Frequency, characteristics, and predictors of microbiologically documented nosocomial infections after cardiac surgery.

OBJECTIVE: Nosocomial infections still remain a serious problem in patients undergoing open heart surgery. The objective of this study was to evaluate frequency, characteristics, and predictors of nosocomial infections after cardiac surgery. METHODS: This prospective case-control study was conducted in adult patients who underwent open heart surgery with use of extracorporeal circulation over a period of 16 months. Cases were patients who developed microbiologically documented nosocomial infection. Controls were patients who had open heart surgery within a randomly selected two-month period of the study (defined before the start of the study) and did not develop nosocomial infection. Various variables, available before, during or within the first two days after operation, were examined as possible risk factors of nosocomial infections in bi-variable analysis. Then, variables that were found to be statistically associated with nosocomial infections in the bi-variable analysis were included in a multivariable logistic regression model to identify independent risk factors associated with nosocomial infections after open heart surgery. RESULTS: One hundred and seven of 2122 (5.0%) patients developed microbiologically documented nosocomial infection after open cardiac surgery. The majority of nosocomial infections were respiratory tract infections (45.7%) and central venous catheter-related infections (25.2%). All cause hospital mortality was 16.8% in patients with nosocomial infection and 3.5% in the control group (p=0.005). Out of 20 variables studied as possible risk factors, 12 had a statistically significant association with postoperative infection. History of immunosuppression (OR=3.6, 95% CI 1.2-11.0%), transfusion of more than five red blood cell units in both the operating room and during the first ICU postoperative day (OR=21.2, 95% CI 11.9-37.8%), and development of acute renal failure within the first two days after operation (OR=49.9, 95% CI 22.4-111.0%), were found to be independent predictors of nosocomial infections after cardiac surgery in a multivariable logistic regression model. CONCLUSIONS: Postoperative nosocomial infections are a considerable problem in cardiac surgery patients. The identified independent predictors of nosocomial infection may be useful in identifying those at high risk for development of such infection in cardiac surgery patients.     

鲍曼不动杆菌医院感染分析及其防治对策

目的 了解鲍曼不动杆菌医院感染情况．为预防其感染提供依据。方法 回顾性调查分析62例鲍曼不动杆菌感染病人资料。结果 鲍曼不动杆菌感染常见于呼吸系统疾病病人,以呼吸道为主;高危科室为1CU;主要诱发因素为住院时间长,广谱抗生素、免疫抑制剂的应用及侵入性治疗;鲍曼不动杆菌对多种抗菌药物耐药．对亚胺培南耐药率最低(1．33％),对氨曲南耐药率最高(89．20％)。结论 需针对鲍曼不动杆菌医院感染的特点,采取相应的防范措施,以预防该菌引起的医院感染。     

A systematic review of movement monitoring devices to aid the prediction of pressure ulcers in at-risk adults

The present study sought to explore the impact of movement monitoring devices on risk prediction and prevention of pressure ulcers (PU) among adults. Using systematic review methodology, we included original research studies using a prospective design, written in English, assessing adult patients' movement in bed, using a movement monitoring device. The search was conducted in March 2021, using PubMed, CINAHL, Scopus, Cochrane, and EMBASE databases, and returned 1537 records, of which 25 met the inclusion criteria. Data were extracted using a pre-designed extraction tool and quality appraisal was undertaken using the evidence-based librarianship (EBL). In total, 19 different movement monitoring devices were used in the studies, using a range of physical sensing principles. The studies focused on quantifying the number and types of movements. In four studies the authors compared the monitoring system with PU risk assessment tools, with a variety of high and low correlations observed. Four studies compared the relationship between movement magnitude and frequency and the development of PUs, with variability in results also identified. Two of these studies showed, as expected, that those who made less movements developed more PU; however, the two studies also unexpectedly found that PUs occurred in both low movers and high movers. In the final two studies, the authors focused on the concordance with recommended repositioning based on the results of the monitoring device. Overall, concordance with repositioning increased with the use of a monitoring device. The synthesis of the literature surrounding bed monitoring technologies for PU risk prediction showed that a range of physical sensors can be used to detect the frequency of movement. Clinical studies showed some correlation between parameters of movement and PU risk/incidence, although the heterogeneity of approaches limits generalisable recommendations.     

Pressure ulcers in cardiac surgery: Few clinical studies,difficult risk assessment,and profound clinical implications

Pressure ulcers (PUs) are a common complication after cardiac surgery, with almost one third of patients suffering from PUs during hospitalisation. Because of the burden that PUs exert on both the patients and the health care system, prevention is of utmost importance. The first step in successful prevention, however, includes the identification of the main features that render patients prone to PU development. Cardiac surgery population is not adequately addressed in current clinical trials and studies. Few studies focused specifically on cardiac surgery patients, but the majority included cardiac surgery patients within a heterogeneous population of acute or critical care patients. Therefore, additional research is warranted to understand the unique risk profile of patients undergoing cardiac surgery. Intraoperative risk factors that affect tissue tolerance have not been thoroughly investigated but are likely to play an important role, which might explain the epidemiology of a PU. Further research is also needed to better comprehend the risk of PUs among cardiac surgery patients and to design effective and tailored preventative measures with the help of newer tools for risk assessment.