Prevention Of Hospital-acquired Pressure Ulcers Research Articles

Effect of an Innovated Turn Clock to Cue Patients' Two-Hourly Repositioning on Prevention of Hospital-acquired Pressure Ulcers among Orthopedic Bedridden Patients

Effect of an Innovated Turn Clock to Cue Patients' Two-Hourly Repositioning on Prevention of Hospital-acquired Pressure Ulcers among Orthopedic Bedridden Patients

Effect of an Innovated Turn Clock to Cue Patients’ Two-Hourly Repositioning on Prevention of Hospital-acquired Pressure Ulcers among Orthopedic Bedridden Patients

Effect of an Innovated Turn Clock to Cue Patients’ Two-Hourly Repositioning on Prevention of Hospital-acquired Pressure Ulcers among Orthopedic Bedridden Patients

A machine learning algorithm for early detection of heel deep tissue injuries based on a daily history of sub-epidermal moisture measurements.

Sub‐epidermal moisture is an established biophysical marker of pressure ulcer formation based on biocapacitance changes in affected soft tissues, which has been shown to facilitate early detection of these injuries. Artificial intelligence shows great promise in wound prevention and care, including in automated analyses of quantitative measures of tissue health such as sub‐epidermal moisture readings acquired over time for effective, patient‐specific, and anatomical‐site‐specific pressure ulcer prophylaxis. Here, we developed a novel machine learning algorithm for early detection of heel deep tissue injuries, which was trained using a database comprising six consecutive daily sub‐epidermal moisture measurements recorded from 173 patients in acute and post‐acute care settings. This algorithm was able to achieve strong predictive power in forecasting heel deep tissue injury events the next day, with sensitivity and specificity of 77% and 80%, respectively, revealing the clinical potential of artificial intelligence‐powered technology for hospital‐acquired pressure ulcer prevention. The current work forms the scientific basis for clinical implementation of machine learning algorithms that provide effective, early, and anatomy‐specific preventive interventions to minimise the occurrence of hospital‐acquired pressure ulcers based on routine tissue health status measurements.

The Effectiveness of Care Bundles Including the Braden Scale for Preventing Hospital Acquired Pressure Ulcers in Older Adults Hospitalized in ICUs: A Systematic Review

Background:Despite technological and scientific advances, Hospital Acquired Pressure Ulcers (HAPUs) remain a common, expensive, but preventable adverse event. The global prevalence ranges from 9% to 53% while three million people develop HAPUs in the United States and 60,000 people die from associated complications. HAPU prevalence is reported as high as 42% in ICUs (ICU) costing on average $48,000 to clinically manage.Objective:The purpose of this systematic review was to evaluate the effectiveness of multi-component interventions (care bundles), incorporating the Braden scale for assessment, in reducing the prevalence of HAPUs in older adults hospitalized in ICUs.Methods:This was a systematic review of the literature using the Cochrane method. A systematic search was performed in six databases (CINAHL, Cochrane Library, Google Scholar, JBI Evidence-Based Practice Database, PubMed, and ProQuest) from January 2012 until December 2018. Bias was assessed with the Critical Appraisal Skills Programme Checklist, and the quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence.Results:The search identified 453 studies for evaluation; 9 studies were reviewed. From the analysis, pressure ulcer prevention programs incorporated three strategies: 1) Evidence-based care bundles with risk assessments upon admission to the ICU; 2) Unit-based skincare expertise; and 3) Staff education with auditing feedback. Common clinical management processes included in the care bundles were frequent risk reassessments, daily skin inspections, moisture removal treatments, nutritional and hydration support, offloading pressure techniques, and protective surface protocols. The Braden scale was an effective risk assessment for the ICU. Through early risk identification and preventative strategies, HAPU programs resulted in prevalence reduction, less severe ulcers, and reduced care costs.Conclusion:Older adults hospitalized in the ICU are most vulnerable to developing HAPUs. Early and accurate identification of risk factors for pressure is essential for prevention. Care bundles with three to five evidence-based interventions, and risk assessment with the Braden scale, were effective in preventing HAPUs in older adults hospitalized in intensive care settings. Higher quality evidence is essential to better understanding the impact of HAPU prevention programs using care bundles with risk assessments on patient outcomes and financial results.

The risks in nursing interventions offered by nurses with the purpose of preventing hospital-acquired pressure ulcers

Abstract The study was performed in seven medical units in Bucharest with the intention to offer a comprehensive analysis of the nurses’ current prevention practices for hospital-acquired pressure ulcers and also to determine: (1) the main risks that can negatively affect the prevention activities for this type of injury, and (2) if there is a correlation between the nurses’ knowledge and the clinical approach to the current hospital-acquired pressure ulcer prevention practices. The statistical analysis was based on data collected from 713 questionnaires from subjects who met the inclusion criteria of the study. The results showed that nurses considered protocols for hospital-acquired pressure ulcer prevention and its management to be important, but both were not always fully implemented into practice due to the lack of resources, time allocation and staff shortages. The regression analysis method we used was focused to assess the predictive capacity for the combined clinical knowledge and professional approaches to hospital-acquired pressure ulcer prevention and management. The conclusion was that a simultaneous improvement in the clinical approaches and professional knowledge on the topic of pressure-ulcer prevention and management may lead to an improvement of up to 6% of the practices in this field according to the results of the statistical analysis performed.

Prevention of Hospital-acquired Pressure Ulcers in Patients with Prone Ventilation: A Retrospective Observational Study

Prevention of Hospital-acquired Pressure Ulcers in Patients with Prone Ventilation: A Retrospective Observational Study

Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In Two Data Sets.

Chart-based surveillance reviews indicate that the incidence of hospital-acquired pressure ulcers (HAPUs) declined 23percent during 2010-14, equating to an estimated savings of $1billion during that period. Yet it remains unclear whether the administrative data used to implement three Medicare value-based purchasing programs that target HAPUs indicate similar improvements, and how success varied by HAPU severity. These programs measure and penalize only for more severe ulcers (stage3 or 4 or unstageable), which are much more costly than less severe cases (stage1 or 2). We assessed HAPU incidence, severity, and trends using administrative data for 2009-14 from three states. The HAPU incidence we found was approximately one-twentieth of that found in chart-based surveillance review data. HAPU incidence in administrative data declined, but 96percent of the change was due to a decline in the incidence of less severe HAPUs. Transitioning from administrative data to chart-based surveillance review to measure HAPUs (mirroring changes that have already been made in reporting hospital-acquired infections) and accounting for HAPU severity could improve the validity of HAPU measures for assessing the clinical and financial impact of value-based purchasing interventions.

Assessment of knowledge and practice & identification of barriers towards pressure ulcer care and prevention among nursing professional

Despite advances in health care, pressure ulcers (PrU) remain one of the most common and serious complications of spinal cord injury (SCI). Prevention of hospital-acquired PrU is an essential prerequisite for early reintegration of SCI patients into the society. Therein, lays the importance of awareness and knowledge about the prevention and management of PrU amongst nurses. The aim of this study was to assess nurses's knowledge of PU management to identify lacunas in implementation of PrU prevention strategies. It was a cross-sectional study. The participants completed a structured performa and Pressure Ulcer Knowledge Test (PUKT), which comprised of 47-items to examine the knowledge on PrU prevention, staging and wound description. A cutoff score of 90% of participants answering an item correctly was used to gauge “adequate” knowledge. Total 240 nurses participated in this study, out of which 87% were female, mean age 42.5 ± 10.49(yrs), more than 50% subjects had work experience of > 20 years. Mean total correct response was 59.01 ± 17.75 and to questions related to ulcer, wound and prevention was 56.19 ± 23.54, 52.98 ± 22.13, and 61.09 ± 18.09, respectively. A satisfactory percentage had adequate knowledge of prevention of PrU. However very poor response was observed to certain questions with only 7(2.92%) answering correctly about the use of Heel protectors and only 37(16.25%) aware about the role of eschar in ulcer healing. The mean PUKT score was < 60% for 41% of the participants. Nursing professionals involved in active care of patients performed significantly better in all the aspects of knowledge test. University training followed by In-service training was the source of education on PrU. Lack of resources and training (25%) & shortage of staff (23%) were the frequently cited barriers to carrying out PrU risk assessment, documentation and prevention. Our study identified deficits in PrU knowledge and areas where nurses would benefit from focused education strategies.

Pressure ulcer prevalence and perceptions on prevention: a hospital-wide survey of health professionals.

Hospital-acquired pressure ulcers (HAPUs) remain a problem despite numerous prevention initiatives. To understand why, it is necessary to know health professionals' perceptions regarding the importance of prevention, and the usability of current initiatives. We hypothesised that positive perceptions of existing initiatives would not be correlated with low HAPU prevalence, and that health professionals would perceive the initiatives to have a low usability. A two-part, online survey was developed and distributed electronically to nurses, in-training physicians and attending physicians, across all inpatient and perioperative departments of an academic hospital. Part one of the survey was the Agency for Healthcare Research and Quality (AHRQ) Staff Attitude Scale on beliefs regarding PU prevention; part two was additional questions on the usability of existing preventative initiatives. The results of the survey were compared with quarterly HAPU prevalence data by hospital unit. In total, 839 health professionals completed the survey (579 nurses, 131 residents, 119 attending physicians). The mean score for the AHRQ survey was 42.5 (≥40 denoting positive perceptions). There was a moderate correlation between AHRQ scores and prevalence of HAPUs (r=-0.60, p=0.402). For usability, repositioning was felt to be the most effective intervention (mean: 4.54, standard deviation (SD): 0.64), while educational posters were felt to be the least effective (mean: 3.31, SD: 0.99). Respondents generally rated satisfaction much lower, with no single initiative significantly better than the others (range: 3.21-3.79). Perceived effectiveness and satisfaction were all positively correlated. High HAPU prevalence, despite position perceptions, suggests that prevention methods are not as effective as thought, or they are not being used as widely as they should. Further research should take advantage of positive attitudes by prospectively investigating the usability of novel interventions.

A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community Hospitals.

The prevention of hospital-acquired pressure ulcers (PrUs) has significant consequences for patient outcomes and the cost of care. Providers are challenged with evaluating available evidence and best practices, then implementing programs and motivating change in various facility environments. In a large system of community hospitals, the Reducing Hospital Acquired-PrUs Program was developed to provide a toolkit of best practices, timely and appropriate data for focusing efforts, and continuous implementation support. Baseline data on PrU rates helped focus efforts on the most vulnerable patients and care situations. Facilities were empowered to use and adapt available resources to meet local needs and to share best practices for implementation across the system. Outcomes were measured by the rate of hospital-acquired PrUs, as gathered from patient discharge records. The rate of hospital-acquired stage III and IV PrUs decreased 66.3% between 2011 and 2013. Of the 149 participating facilities, 40 (27%) had zero hospital-acquired stage III and IV PrUs and 77 (52%) had a reduction in their PrU rate. Rates of all PrUs documented as present on admission did not change during this period. A comparison of different strategies used by the most successful facilities illustrated the necessity of facility-level flexibility and recognition of local workflows and patient demographics. Driven by the combination of a repository of evidence-based tools and best practices, readily available data on PrU rates, and local flexibility with processes, the Reducing Hospital Acquired-PrUs Program represents the successful operationalization of improvement in a wide variety of facilities.

Turning frequency in adult bedridden patients to prevent hospital-acquired pressure ulcer: A scoping review.

The aim of this study was to identify current research on turning frequencies of adult bed-bound patients and inform future turning practices for hospitals based on evidence-based practice. We undertook a scoping review framework that provided a transparent and systematic methodology using 8 electronic databases (CINAHL, PubMed, Cochrane Library, ScienceDirect, PsycINFO, Scopus, ProQuest, and Web of Science) to identify articles published from 2000 to 2016. Articles were included if they focused on the prevention of hospital-acquired pressure ulcers related to the frequency of turning or repositioning of bed-bound patients. Literature search and data extraction were performed independently by 3 authors. The study followed the PRISMA guidelines. In total, 911 articles were identified, of which 10 were eligible. Of the eligible articles, 8 studies could not reach a conclusion on the effective frequency of turning and duration for repositioning patients to prevent the development of pressure ulcers. Only 2 studies found significant differences among the intervention and control groups. Results regarding turning and repositioning schedules are inconclusive; however, the topic needs further exploration to improve the outdated guidelines surrounding pressure ulcer prevention. This may, in turn, make the work of nurses more efficient and make treatment cost-effective for both the patients and the hospitals.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration

In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs). During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention. For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p < 0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p < 0.001). Staff education and documentation improvement were the most frequently implemented changes. This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement.

Enhancing Documentation of Pressure Ulcer Prevention Interventions: A Quality Improvement Strategy to Reduce Pressure Ulcers.

Prevention of hospital-acquired pressure ulcers requires the implementation of evidence-based interventions. A quality improvement project was conducted to provide nurses with data on the frequency with which pressure ulcer prevention interventions were performed as measured by documentation. Documentation reports provided feedback to stakeholders, triggering reminders and reeducation. Intervention reports and modifications to the documentation system were effective both in increasing the documentation of pressure ulcer prevention interventions and in decreasing the number of avoidable hospital-acquired pressure ulcers.

Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers?

In 2008, the Centers for Medicare and Medicaid Services (CMS) established nonpayment policies resulting from costliness of hospital-acquired pressure ulcers (HAPUs) to hospitals. This prompted hospitals to adopt quality improvement (QI) interventions that increase use of evidence-based practices (EBPs) for HAPU prevention. To evaluate the longitudinal impact of CMS policy and QI adoption on HAPU rates. We characterized longitudinal adoption of 25 QI interventions that support EBPs through hospital leadership, staff, information technology, and performance and improvement. Quarterly counts of HAPU incidence and inpatient characteristics were collected from 55 University HealthSystem Consortium hospitals between 2007 and 2012. Mixed-effects regression models tested the longitudinal association of CMS policy, HAPU coding, and QI on HAPU rates. The models assumed level-2 random intercepts and random effects for CMS policy and EBP implementation to account for between-hospital variability in HAPU incidence. Controlling for all 25 QI interventions, specific updates to EBPs for HAPU prevention had a significant, though modest reduction on HAPU rates (-1.86 cases/quarter; P=0.002) and the effect of CMS nonpayment policy on HAPU prevention was much greater (-11.32 cases/quarter; P<0.001). HAPU rates were significantly lower after changes in CMS reimbursement. Reductions are associated with hospital-wide implementation of EBPs for HAPU prevention. Given that administrative data were used, it remains unknown whether these improvements were due to changes in coding or improved quality of care.

Using heel protectors for the prevention of hospital-acquired pressure ulcers.

Pressure ulcers are a frequent, but often preventable, occurrence among patients in acute care facilities, and the heel is one of the anatomical locations most commonly affected. Multiple clinical guidelines recommend the use of robust assessments to identify at-risk patients and the application of heel protection devices to reduce the likelihood of developing heel pressure ulcers. A quality improvement initiative involving robust skin-assessment practices, staff education, and the use of heel protection devices was analysed retrospectively to evaluate the efficacy of current practice interventions. These analyses revealed that the incidence of heel pressure ulcers was inversely correlated with the number of heel protectors used at two large acute NHS teaching hospitals in inner London, and that the consistent and early use of heel protectors improved patient outcomes and reduced costs of care.

Predicting the risk of hospital-acquired pressure ulcers in intensive care unit patients based on decision tree

Objective To explore and evaluate the feasibility and accuracy of applying decision tree methods to predict the risk of hospital-acquired pressure ulcers (HAPUs) in intensive care unit (ICU) patients, and provide a theoretical basis for the prevention of HAPUs in clinical practice. Methods A retrospective design was used to collect 468 patients' records, and all of the patients were hospitalized in ICUs including medical intensive care unit and coronary care unit between October 2011 and October 2013 in a 3 A grade hospital in Guangzhou. The CART algorithm was used to construct the decision tree risk prediction model. The area under the receiver operating curve (AUC), sensitivity and specificity were used to evaluate the predictive validity of the decision tree model compared with the Braden Scale. Results The decision tree model had four stratums and eleven nodes. Six classification rules and three styles of high-risk populations were screened out: (1)age >81; (2)age ≤81 combined with fecal incontinence; (3)age ≤81 combined with total Braden score ≤13 and diastolic blood pressure < 60mmHg (1 mmHg= 0.133 kPa). The AUC of the decision tree model was significantly higher than the Braden Score (Z=2.31,P < 0.05). The sensitivity and specificity of the decision tree model (0.809 and 0.703) were higher than the Braden Score (0.777 and 0.587). Conclusions The decision tree model is an easy and feasible tool to predict the risk of HAPUs in ICU patients, and it can be used to screen high-risk populations. Key words: Intensive care units; Pressure ulcer; Decision tree; Prediction

Use of a Comprehensive Program to Reduce the Incidence of Hospital-Acquired Pressure Ulcers in an Intensive Care Unit.

Hospital-acquired pressure ulcers (HAPUs) are a costly and largely preventable complication occurring in a variety of acute care settings. Because they are considered preventable, stage III and IV HAPUs are not reimbursed by Medicare. To assess the effectiveness of a formal, year-long HAPU prevention program in an adult intensive care unit, with a goal of achieving at least a 50% reduction in 2013, compared with 2011. Planning for the prevention program began in 2012, and the program was rolled out in the first quarter of 2013. Program components included use of Braden scores, a revised skin care protocol, fluidized repositioners, and silicone gel adhesive dressings. Efforts were made to educate and motivate staff and encourage them to be more proactive in detecting patients at risk of HAPUs. Incidence of HAPUs in the unit was reduced by 69% (n = 17; 3% of patients in 2013 vs n = 45, 10% of patients in 2011), despite a 22% increase in patient load. The potential cost saving as a result of this decrease was approximately $1 million. A comprehensive, proactive, collaborative ulcer prevention program based on staff education and a focus on adherence to protocols for patient care can be an effective way to reduce the incidence of HAPUs in intensive care units.

Inpatient Pressure Ulcer Prevalence in an Acute Care Hospital Using Evidence‐Based Practice

A national goal was set in 2004 for decreasing hospital-acquired pressure ulcers (HAPUs). A mean to achieve that goal was initiated in 2005 with long-term care facilities. Acute care facilities, with encouragement from the Centers for Medicare and Medicaid Services, took action. Pressure ulcer prevention efforts at MaineGeneral Medical Center (MGMC), a 192-bed acute care hospital in Augusta, Maine, sought to reduce HAPU prevalence from a mean of 7.8% in 2005. A retrospective study over a 10-year period, from 2005 through 2014, tracked HAPUs and evidence-based practice (EBP) initiatives to decrease the annual mean prevalence rate. The annual mean HAPU prevalence rate of 7.8% in 2005 decreased to 1.4% in 2011, then maintaining this level through 2014 at MGMC. Evidence-based practices for pressure ulcer prevention were implemented using data collection tools from the National Database of Nursing Quality Indicators; guidelines from the National Pressure Ulcer Advisory Panel; and procedural guidance tools from the 5 Million Lives Campaign and the Agency for Healthcare Research and Quality. Accurate data collection methods and evidence-based guidelines are vital to improving care; yet planning with annual review, fostering an EBP culture, by-in of stakeholders, and education, are the means to long-term consistent implementation of pressure ulcer prevention measures. Keys to decreasing and maintaining the rate were based on effective scientific evidence for prevention of pressure ulcers: assessment tools, education, planning guidance, documentation, and evidence-based practice guidelines.

Increased Adoption of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention in U.S. Academic Medical Centers.

In 2008, the U.S. Centers for Medicare and Medicaid Services enacted a nonpayment policy for stage III and IV hospital-acquired pressure ulcers (HAPUs), which incentivized hospitals to improve prevention efforts. In response, hospitals looked for ways to support implementation of evidence-based practices for HAPU prevention, such as adoption of quality improvement (QI) interventions. The objective of this study was to quantify adoption patterns of QI interventions for supporting evidence-based practices for HAPU prevention. This study surveyed wound care specialists working at hospitals within the University HealthSystem Consortium. A questionnaire was used to retrospectively describe QI adoption patterns according to 25 HAPU-specific QI interventions into four domains: leadership, staff, information technology (IT), and performance and improvement. Respondents indicated QI interventions implemented between 2007 and 2012 to the nearest quarter and year. Descriptive statistics defined patterns of QI adoption. A t-test and statistical process control chart established statistically significant increase in adoption following nonpayment policy enactment in October 2008. Increase are described in terms of scope (number of QI domains employed) and scale (number of QI interventions within domains). Fifty-three of the 55 hospitals surveyed reported implementing QI interventions for HAPU prevention. Leadership interventions were most frequent, increasing in scope from 40% to 63% between 2008 and 2012; "annual programs to promote pressure ulcer prevention" showed the greatest increase in scale. Staff interventions increased in scope from 32% to 53%; "frequent consult driven huddles" showed the greatest increase in scale. IT interventions increased in scope from 31% to 55%. Performance and improvement interventions increased in scope from 18% to 40%, with "new skin care products . . ." increasing the most. Academic medical centers increased adoption of QI interventions following changes in nonpayment policy. These QI interventions supported adherence to implementation of pressure ulcer prevention protocols. Changes in payment policies for prevention are effective in QI efforts.

Nurse Continuity and Hospital-Acquired Pressure Ulcers: A Comparative Analysis Using an Electronic Health Record "Big Data" Set.

Little research demonstrating the association between nurse continuity and patient outcomes exists despite an intuitive belief that continuity makes a difference in care outcomes. The aim of this study was to examine the association of nurse continuity with the prevention of hospital-acquired pressure ulcers (HAPU). A secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care data set containing 42,403 episodes documented by 787 nurses, on nine units, in four hospitals and includes nurse staffing and patient characteristics. The HANDS data set resides in a "big data" relational database consisting of 89 tables and 747 columns of data. Via data mining, we created an analytic data set of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the association of nurse continuity and additional nurse-staffing variables on HAPU occurrence. Poor nurse continuity (unit mean continuity index = .21-.42 [1.0 = optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission, as well as patient age, were associated with HAPUs (p < .001). Controlling for patient characteristics, nurse continuity, and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development. Patient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. We demonstrated a high level of variation in the degree of continuity between patient episodes in the HANDS data, showing that it offers rich potential for future study of nurse continuity and its effect on patient outcomes.