Pressure Ulcer Prevalence and Incidence in a Rehabilitation Hospital

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.     

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.     

Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact

OBJECTIVE: To investigate the characteristics, predictors, and consequences of pressure ulcers in patients with nontraumatic spinal cord injury (SCI). DESIGN: Retrospective, 3-year, case series. SETTING: Tertiary medical unit specializing in SCI rehabilitation. PARTICIPANTS: Consecutive sample of 134 adult inpatient referrals with nontraumatic SCI. Patients requiring initial rehabilitation or readmission were included. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcome measures were presence of pressure ulcers on admission to rehabilitation, incidence of new pressure ulcers developing during hospitalization, and any complications attributable to pressure ulcers during inpatient rehabilitation. Secondary objectives were to examine the predictability of risk factors for pressure ulcers, to assess the usefulness of a model previously developed for predicting pressure ulcers in patients with chronic SCI, and to estimate the effect of pressure ulcers on rehabilitation of nontraumatic SCI. RESULTS: Prevalence of pressure ulcers among admissions was 31.3% (n=42). Only 2.2% (n=3) of patients developed a new pressure ulcer after admission. The length of stay (LOS) of patients admitted with a pressure ulcer was significantly longer than that of those without a pressure ulcer (geometric mean, 62.3 d for pressure ulcer vs 28.2 d for no pressure ulcer, P=.0001). Many previously identified risk factors for pressure ulcers in SCI patients did not apply to our nontraumatic SCI patients. It is estimated that the inpatient LOS for those patients with a significant pressure ulcer was increased by 42 days. CONCLUSIONS: Pressure ulcers are a common complication for people with nontraumatic SCI who are admitted for rehabilitation, and they have a significant impact on LOS.     

The prevalence and incidence of pressure ulcers in hospitalised patients in the Netherlands: a prospective inception cohort study

BACKGROUND: Pressure ulcers frequently occur in hospitalised patients. The prevalence of pressure ulcers grade 2 or worse varies from 3% to 12% in hospitalised patients. Incidence figures are not frequently reported. While incidence and prevalence are both measures of disease frequency, they provide different perspectives on pressure ulcers. OBJECTIVES: To describe the incidence rate and prevalence of pressure ulcers in hospitalised patients. DESIGN: Prospective inception cohort study. SETTING: Two large hospitals, one general (530-beds) and one teaching (1042-beds), in The Netherlands. PARTICIPANTS: A non-selected, though not strictly random, sample of 1536 patients was eligible for inclusion in the study. One thousand four hundred and thirty one patients (93.2%) consented to participate. Eventually, 1229 patients (80%) had a complete follow-up. The sample consisted of patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days between January 1999 and June 2000. METHODS: Follow-up once a week until pressure ulcer occurrence, discharge or length of stay over 12 weeks. MAIN OUTCOME MEASURES: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital, according to the classification of the European Pressure Ulcer Advisory Panel. RESULTS: One hundred and thirty four patients developed 172 pressure ulcers during follow-up. The overall weekly incidence rate was 0.06 per week (95% confidence interval 0.05-0.07 per week). Highest rates were observed for surgical patients and lowest for geriatric and neurologic patients (0.08 and 0.02, respectively). The week specific prevalence varied between 12.8% and 20.3%. CONCLUSIONS: Among patients hospitalised for more than 5 days overall one may expect 6% per week to develop pressure ulcers. It would appear that any preventive measures can only be effective if taken timely. Accordingly, preventive measures should be considered early, because pressure ulcers were observed already within the first week of admission.     

Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study

Background

Pressure ulcers are common in acute and long-term care. However, critically ill patients usually have multiple risk factors for pressure ulcers.

Objectives

The study was conducted to assess pressure ulcer incidence in intensive care patients, the factors related to pressure ulcer incidence and the course of pressure ulcers after the admission to an intensive care unit.

Design

A longitudinal design.

Setting

This study was carried out in cardiological and surgical intensive care of a general hospital and in a nephrological intensive care of a university hospital.

Participants

All patients admitted to intensive care wards during the period from April until October 2006 were invited to take a part in the study. One hundred and twenty-one patients were involved in the study. The inclusion criteria were adult intensive care patients, males and females, all diagnosis were included. The exclusion criterion was patients whose age less than 18 years.

Method

Each patient was assessed twice; first, upon admission and second upon discharge or death, or after 2 weeks if the patient was still in intensive care. The assessed data included pressure ulcer preventive measures, risk factors using Braden score, pressure ulcer characteristics and treatment. Additionally, incontinence supplies (urine/bowel) if used and the severity of illness using Acute Physiology and Chronic Health Evaluation (APACHE II score) were assessd.

Results

This study revealed a total incidence of 3.3% (4.5% in nephrological patients and 2.9% in surgical patients). Sixteen patients with a total of 21 pressure ulcers were admitted to the intensive care units. During the patients’ stay at the intensive care units six pressure ulcers developed newly and five pressure ulcers healed. The mean of the APACHE II score of patients with new pressure ulcers (16.6) were higher than in patients without new pressure ulcers (11.5).

Conclusion

Pressure ulcer incidence is low in this study compared to other studies. Pressure ulcers can be healed in intensive care patients. Using some preventive measures such as foam and alternating air pressure mattresses may help to decrease pressure ulcer development. Hydrocolloid dressing may help to increase the healing rate of pressure ulcers.     

Pressure sores: evaluation of the systematic use of special surfaces for managing pressure sores in the intensive care unit of the Tarrasa Hospital, Spain

Pressure sores are a major challenge for healthcare systems. Patients admitted to intensive care units are an important risk group for pressure sores. Systematic use of a protocol employing special surfaces to manage pressure is a basic measure for preventing pressure sores in institutionalized patients. In a study carried out in the Intensive Care Unit of the Hospital of Terrassa (Spain), the incidence of pressure sores before and after introducing a prevention protocol that included the systematic use of special surfaces to manage pressure was compared. The incidence of pressure sores in patients admitted in 1998 and 1999 was studied. Sore locations were recorded. The results of three periods were examined: before introducing the protocol (6.4% incidence), after introducing a protocol (1.1%), and after use of the protocol was consolidated (0%). The results of the study suggest that the systematic use of special surfaces to manage pressure, in accordance with a prevention protocol, is a basic measure for reducing the incidence of pressure sores in patients admitted to intensive care units.     

Spinal cord injury in Italy: A multicenter retrospective study

OBJECTIVE: To investigate certain factors influencing the length of stay (LOS) in a rehabilitation center, the incidence of pressure ulcers, and the neurologic improvement of patients with traumatic (T/SCI) and nontraumatic spinal cord injury (NT/SCI). DESIGN: A multicenter retrospective study of patients with SCI admitted to rehabilitation centers between 1 January 1989 and 31 December 1994 (only first admissions). SETTING: Seven Italian rehabilitation centers. PATIENTS: A total of 859 consecutively admitted adult patients with SCI. INTERVENTION: Examined medical records of patients admitted to rehabilitation centers. MAIN OUTCOME MEASURES: Pressure ulcers on admission as an indicator of nursing care in acute phase, LOS in rehabilitation centers, and neurologic improvement on discharge (using the Frankel classification system). Other measures included level of lesion, associated lesions (if T/SCI), surgical stabilization (if T/SCI), and time from the event to admission to a rehabilitation center. RESULTS: In all cases, the time from event to admission to a rehabilitation center exceeded 30 days (average +/- standard deviation: T/SCI, 54.6 +/- 43.7d; NT/SCI, 166.9 +/- 574d); pressure ulcers on admission were present in 34.1% of T/SCI and 17.1% of NT/SCI patients. The average LOS in a rehabilitation center was 143.1 +/- 89.1 days for T/SCI and 91.7 +/- 78.9 days for NT/SCI; Frankel grades improved by 1 or more in 34.4% of T/SCI and 34.1% of NT/SCI patients. The presence of pressure ulcers on admission, rehabilitation LOS, and neurologic improvement on discharge correlated highly with severe neurologic damage on admission in both T/SCI and NT/SCI patients as well as with management of the patient immediately before admission to a rehabilitation center, mainly in NT/SCI patients. CONCLUSIONS: Severe neurologic damage is the major determining factor in predicting neurologic recovery. Pressure ulcer prevention is statistically associated with neurologic improvement and the shortening of rehabilitation LOS. Patient management immediately before admission to rehabilitation has a statistical correlation with neurologic improvement in all patients studied and on both rehabilitation LOS and incidence of pressure ulcers in the NT/SCI patients.     

Predicting pressure ulcers: cases missed using a new clinical prediction rule

AIM: The aim of this paper is to report a study describing patients with pressure ulcers that were incorrectly classified as 'not at risk' by the prediction rule and comparing them with patients who were correctly classified as 'not at risk'. BACKGROUND: Patients admitted to hospital are at risk of developing pressure ulcers. Although the majority of pressure ulcers can be predicted using a recently developed prediction rule, up to 30% of patients with pressure ulcers may still be misclassified. METHODS: Between January 1999 and June 2000 a prospective cohort study was conducted in two large hospitals in the Netherlands. Patients admitted to neurology, internal, surgical, and elder care wards for more than 5 days were included (n = 1229), and were examined weekly. Information on potential prognostic determinants for pressure ulcers mentioned in the literature was recorded. Outcome was defined as occurrence of a pressure ulcer grade 2 or worse during hospital admission. RESULTS: Patients who developed pressure ulcers experienced more problems with 'friction and shear' and underwent surgery more often and longer. Also, they were more often admitted because of malignant conditions. CONCLUSION: We found no specific characteristics that clearly distinguished patients with pressure ulcers that were incorrectly classified as 'not at risk' by the prediction rule from patients who were correctly classified as 'not at risk'. It appears difficult to improve further on the prediction of pressure ulcers using available clinical information.     

Evaluation of patient outcomes: pressure ulcer prevention mattresses

This article reports the findings of a small evaluation audit which compares the Dyna-Form Mercury Advance Mattress to that of the Softform Premier Active Mattress (a foam mattress with dynamic underlay). A small group of patients with similar co-morbidities who were an emergency admission were recruited to an evaluation audit. Their median age and Waterlow score indicated that these patients were at high risk of pressure ulcer development. All patients were given the same nursing care on the two mattresses and all were moved, handled and repositioned 2-4 hourly. Of the patients nursed on the Dyna-Form Mercury Advance mattress, three did not develop pressure ulcers. The two who already had pressure ulcers when they were recruited appeared to have healed within four days. Of the patients nursed on the Softform Premier Active mattress, three patients did not develop ulcers and two did. Although the sample size was small, the comprehensive assessment gave interesting results, particularly on the Dyna-Form Mercury Advance. A larger study may be of benefit to demonstrate efficacy of these products further.     

Treatment of chronic skin lesions

Leg Ulcers as well as Pressure Sore Ulcers are a pathology, although considered different due to their ethiology, that have a common denominator of the possibility to be healed using a moist wound healing environment. Taking advantage of this interesting therapeutic alternative, a multicentric, open, prospective study was carried out in order to evaluate the behaviour and efficiency of the new alveolar tridimensional structure hydropolymetric dressing, in the treatment of both leg ulcers and pressure sore ulcers, all with moderate to high exudate. The results obtained confirm the efficiency of the dressing in the pathology studied, along with the high acceptance of the hydropolimetric dressing chosen by the professionals and the excellent adaptation to the patients needs.     

Factors influencing the development of decubitus ulcers in critically ill surgical patients

INTRODUCTION: Decubitus ulcers confer significant morbidity to critically ill patients. We sought to determine which patient factors contributed to the formation of decubitus ulcers in our critically ill patients, and hypothesized that these ulcers occurred most often in elderly patients with lengths of stay >7 days and high severity of illness. METHODS: This study was conducted prospectively in two phases. Phase I provided an initial analysis of patients who developed decubitus ulcers in the surgical intensive care unit (ICU) of New York Weill Cornell Center from January 1, 1993, to June 1, 1997. In phase II of the study, a comparison study was made for patients with ICU length of stay (ULOS) >7 days admitted to the same ICU from January 1, 1998, to August 31, 1998. Age, APACHE III score, systemic inflammatory response syndrome (SIRS score), multiple organ dysfunction syndrome (MODS) score, admission status, days without nutrition, ULOS, mortality, days to formation of decubitus ulcers, Cornell ulcer risk score, and other demographic features were recorded. Univariate and multivariate analysis of variance were performed to analyze independent risk factors for development of decubitus ulcers; p <.05. RESULTS: In phase I, 2,615 patients were admitted to surgical ICU over the study period. One hundred and one decubitus ulcers occurred (incidence 3.8%) during phase I, but the incidence of decubitus ulcers increased significantly over time to 9% (p <.01). Thirty-three decubitus ulcers occurred among the 412 patients (incidence 8.0%) during phase II. Multivariate analysis revealed that emergent admission (odds ratio [OR] 36.00, 95% confidence interval [CI] CI 0.2290-0.7694), age (OR 1.08, 95% CI 0.0026-0.0131), days in bed (OR 1.05, 95% CI -0.0013-0.0156, and days without nutrition (OR 0.51, 95% CI -0.1095--0.0334) were independent predictors of a decubitus ulcer. CONCLUSIONS: The incidence of decubitus ulcers is increasing in critically ill patients. Emergency ICU admission and ULOS >7 days in elderly patients confer significant risk for the formation of decubitus ulcers. Specific interventions targeting this high-risk population that may be instituted to decrease the incidence of decubitus ulcers include early nutrition, early mobilization, and possibly less noxious bedding surfaces.     

Risk factors for early occurring pressure ulcers following spinal cord injury

We carried out a prospective study to determine the association between immobilization in the immediate postinjury period and the development of pressure ulcers in spinal cord-injured patients following their admission to Charity Hospital, New Orleans. Of 39 patients consecutively admitted to the hospital, 23 (59%) developed a grade one ulcer within 30 days, mostly in the sacral region (57%), the peak time of onset being day 4 postinjury (6/23 cases). In partial support of an earlier retrospective study (Linares HA, Mawson AR, Suarez E, Biundo JJ Jr: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-573), duration of unrelieved pressure prior to ward admission was significantly associated with ulcers developing within the first eight days of injury (P = 0.04), but not with ulcers developing during the entire 30-day observation period (P = 0.09). Time on the spinal board was also significantly associated with ulcers developing within 8 days (P = 0.01), but not with ulcers developing within 30 days (P = 0.09). An unexpected finding was the significant inverse association between systolic blood pressure and the development of ulcers both within 8 days (P = 0.03) and within 30 days (P = 0.02), suggesting that reduced tissue perfusion increases the spinal cord-injured patient's susceptibility to pressure ulcers.     

Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial

Aims and objectives. To evaluate whether postponing preventive measures until non‐blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2–4) when compared with the standard risk assessment method. Background. To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non‐blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach. Design. Randomized‐controlled trial. Methods. Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non‐blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non‐blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene–urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days. Results. In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2–4) was not significantly different between the experimental (6·8%) and control group (6·7%). Conclusion. Significantly fewer patients need preventive measures when prevention is postponed until non‐blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method. Relevance to clinical practice. Using the appearance of non‐blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.     

The prevalence of pressure ulcers in four paediatric institutions

Aim and objective. Pressure ulcers are a common nursing care issue in hospitals. They are associated with psychological and physical suffering, an increased morbidity and mortality rate and higher overall health care costs. The aim of the current study is to describe the frequency of pressure ulcers in a paediatric care setting and to identify the population at risk, as well as to assess the factors predisposing to the development of pressure ulcers. Design. A point prevalence study. Methods. The study was conducted in four paediatric hospitals in the German‐speaking part of Switzerland and included children from the age of 0–18 years. The method of data collection was a direct systematic inspection and assessment of the skin, taking into account the clinical condition of the patient for risk assessment. A valid risk assessment and data collection instrument was used and, each patient was assessed by a previously instructed rater pair. Results. Of all possible patients, 81% (n = 155) were included. An overall pressure ulcer prevalence of 27·7% (including grade 1) was registered. Thirty‐six patients (84%) had grade 1 ulcers, including many caused by external medical devices. Sixty‐five per cent (n = 100) of all patients were considered at risk (Braden score ≤ 20) of developing a pressure ulcer. Thirty‐five per cent of patients in the risk group were afflicted with one or more pressure ulcers. Conclusions. The prevalence of pressure ulcers in paediatric patients is greater then previously appreciated and the problem requires further exploration. The high percentage of grade 1 pressure ulcers caused by medical devices requires nursing interventions to prevent lesions for these patients. Relevance to clinical practice. The high prevalence rate in paediatric patients is disconcerting and requires further exploration in terms of interventions needed to improve outcomes for this patient group.     

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

Aims and objectives. To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention. Background. Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care. Methods. A cross‐sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence. Results. There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6·8%. The age‐, sex‐ and risk‐standardized prevalence per regional department varied between 4·9% and 9·1%. Of the 744 subjects at risk, 33 (4·4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64·8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30·8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4·8% adherence, 76·6% no adherence and 18·6% no prevention. A proportion of 22·2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21·4% of all risk cases. Conclusions. The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. Relevance to the clinical practice. The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.     

La educación como pieza clave en la prevención y buena evolución de las úlceras por presión

ObjectiveTo evaluate if an education program for the nursing staff helps to reduce the incidence of pressure ulcers and prevent their poor evolution.Material and methodsA prospective and observational study where the prevention and educational methods have been used to prevent and treat pressure ulcers. All patients has admitted to Intensive Care Unit during one year were included (six months of basal period and six months of post-training period). The following variables were analyzed: incidence of Pressure Ulcers, risk score according to EMINA, ulcer grade and location.ResultsA total of 134 ulcers were identified in the 69 patients (14.37%) with pressure ulcers included in the basal period. Forty-four patients (7.88%) of the patients in the post-training period developed 77 pressure ulcers. The significance level was p < 0.01, OR: 0.40 (95% CI: 0.26-0.62). Fifteen of the 211 pressure ulcers evolved to grade III-IV p > 0.20.ConclusionsConducting a training program in the application of standardized prevention methods for the nursing staff reduces the incidence of pressure ulcers.     

Pressure ulcer risk factors in patients undergoing surgery

AIM: This paper reports a study to identify risk factors associated with pressure ulcer development among a mixed group of adult patients undergoing surgery. BACKGROUND: Few studies have been carried out with patients undergoing surgery to assess the risk of pressure ulcer development, and so there is a little knowledge of the risk factors for this group. However, studies among non-surgical patients have shown that nutritional predictors such as low serum albumin level and low body mass index (BMI) are of great importance. An additional predictive factor may be low blood pressure. It is important to study these predictors further among patients undergoing surgery, using techniques such as multiple regression techniques, designed to identify the most important predictors for pressure ulcer development. METHODS: A prospective comparative study was carried out in 1996-1998 with 286 adult patients undergoing surgical treatment. The data were collected from patient records by Registered Nurses preoperatively, for seven days postoperatively and thereafter once a week for up to 12 weeks. Perioperative data were also collected. The Risk Assessment Pressure Sore Scale was used, and data were collected on general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear, body temperature and serum albumin. RESULTS: Forty-one (14.3%) patients developed pressure ulcers during the observation period. The most common type was non-blanchable erythema. Those who developed pressure ulcers were significantly older, weighed less, and had a lower BMI and serum albumin. More women than men developed pressure ulcers. Risk factors identified in multiple stepwise regression analyses were female gender, American Society of Anaesthesiologists (ASA) status or New York Heart Association (NYHA) status and food-intake. CONCLUSION: Special attention, with regard to risk of pressure ulcer development, should be paid to patients undergoing surgery who have low ASA or NYHA scores, low food intake and/or are women.