Hospital-acquired Pressure Ulcers Research Articles

Evidence-Based Practice Guideline: Delirium.

Delirium is a common cause of morbidity and mortality in hospitalized older adults often superimposed on dementia. Older patients with delirium are more likely than other populations to develop hospital-acquired infections, pressure ulcers, and immobility and nutritional issues, as well as to have increased health care costs, longer hospital stays, and long-term care following discharge. Interventions that prevent or mitigate the effects of delirium while promoting recovery are essential for caring for hospitalized older patients. This article is a summary of an evidence-based guideline that includes a framework for addressing delirium that focuses on predisposing and precipitating factors for delirium. In addition, the guideline includes evidence-based assessment and intervention principles, along with a review of reliable and valid assessment instruments. The guideline also identifies measurable outcomes for managing delirium and a quality improvement approach for improving outcomes. [Journal of Gerontological Nursing, 44(2), 14-24.].

Evaluation of the Present-on-Admission Indicator among Hospitalized Fee-for-Service Medicare Patients with a Pressure Ulcer Diagnosis: Coding Patterns and Impact on Hospital-Acquired Pressure Ulcer Rates.

To evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates. Medicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011). Retrospective cross-sectional study. We evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria. Among admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations. As payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

Effectiveness of care bundle for hospital acquired pressure ulcer in ICU

Effectiveness of care bundle for hospital acquired pressure ulcer in ICU

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.

The Design and Implementation of a Local Strategy to Increase the Accuracy of Pressure Ulcer Classification: The Pressure Ulcer Guidance (PUG) Tool

Skin inspection should be seen as an essential part of patient assessment and therefore should be compulsory for all hospital admissions. Recognising this as a key factor of risk assessment can ensure healthcare professionals are providing the best possible care and protection for their patients. Identifying skin damage on initial assessment ensures appropriate and early intervention, thus minimising or even preventing the risk of damage to the skin and avoiding pressure ulcer development. Once a pressure has developed the patient is generally dependent on others to manage, treat and care for their ulcer. Healthcare providers need to recognise that a pressure ulcer is a crucial element in preventing a full recovery, it can lead to increased hospital stay, resulting in ongoing treatment which may take weeks, even months of nursing care. Patients may also experience pain and discomfort, which has serious consequences on a patient’s quality of life, as well as a very costly exercise for the National Health Service (NHS). Understanding the mechanism of how the skin can be damaged and identifying the different stages of pressure damage can help in reducing, or even avoiding hospital acquired pressure ulcers. However, failure to identify pressure ulcers correctly can lead to inaccurate reporting and consequently inappropriate management. This article aims to explain the development and introduction of a new strategy to aid healthcare professionals overcome the difficulties in classifying pressure ulcers and differentiating superficial pressure ulcers from moisture lesions. Using the European Pressure Ulcer classification guide (EPUAP 2014) a pressure ulcer guide wheel, or ‘PUG wheel/ tool’, was designed to help healthcare professionals understand pressure ulcer categories and differentiate between pressure ulcers and moisture lesions [1]. To test the accuracy regarding classification, a group of 20 Tissue Viability Link Nurses were tested using this new tool against various verified pressure ulcer and moisture lesion images. A supporting poster was also designed to help healthcare professionals understand the staging system.

Applying the PDSA Framework to Examine the Use of the Clinical Nurse Leader to Evaluate Pressure Ulcer Reporting

The clinical nurse leader (CNL) role has been cited as an effective strategy for improving care at the microsystem level. The purpose of this article is to describe the use of the CNL role in an academic medical center for evaluating pressure ulcer reporting. The Plan-Do-Study-Act cycle was used as the methodological framework for the study. The CNL assessment of pressure ulcers resulted in a 21% to 50% decrease in the number of hospital-acquired pressure ulcers reported in a 3-month time period. The CNL role has potential for improving the validity and reliability of pressure ulcer reporting.

Reducing hospital-acquired pressure ulcers using bundle methodology in pediatric and neonatal patients receiving extracorporeal membrane oxygenation therapy: An integrative review and call to action.

This review focuses on identifying (1) evidence of the effectiveness of care bundle methodology to reduce hospital-acquired pressure ulcers (HAPUs) in pediatric and neonatal patients receiving extracorporeal membrane oxygenation (ECMO) therapy and (2) barriers to implementing HAPU care bundles in this at-risk population. An integrative review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search of the scientific literature was performed. Studies included were published between January 2011 and February 2016. A total of seven articles met inclusion criteria. Data were extracted from each published article and analyzed to identify common themes, specifically bundle methodology and barriers to implementing HAPU bundles, in this population. There is limited research on effectiveness of care bundle methodology in reducing HAPUs in children, and no research specific to its effectiveness in pediatric or neonatal ECMO patients. No research was identified studying barriers to implementation of HAPU care bundles in this population. Nurses are well poised to test innovative strategies to prevent HAPUs. Nurses should consider implementing and testing bundle methodology to reduce HAPU in this at-risk population, and conduct research to identify any barriers to implementing this strategy. There is literature to support the use of nurses as unit-based skin care champions to facilitate teamwork and reliable use of the bundle, both critical components to the success of bundle methodology.

A safety culture training program enhanced the perceptions of patient safety culture of nurse managers.

Positive perceptions of patient safety culture are associated with lower rates of adverse events, but they have not been widely established in many health care organizations. The purpose of this study is to examine the impacts of a safety culture training program (SCTP) on enhancing the perceptions of patient safety in nurse managers. This was a quasi-experimental design. 83 nurse managers were recruited from five randomly selected 2nd level hospitals. Sixty-seven nurse managers received training under the educational SCTP. The Hospital Survey on Patient Safety Culture (HSPSC) and Chinese Safety Attitudes Questionnaire (C-SAQ) were administered just before and six months after the educational program. The data of hospital-acquired pressure ulcers, patient falls, and unplanned extubations were collected. The total positive scores of HSPSC were significantly improved and four dimensions of C-SAQ significantly increased six months after SCTP. The rate of patient falls and rate of hospital-acquired pressure ulcers decreased significantly six months post SCTP. In conclusion, nurse manager participation in a SCTP can enhance the perceptions of patient safety and reduce the rates of adverse events. More rigorous trials with larger numbers of participants and a control group are needed to strengthen the conclusions.

Exploration of the Use of the Scott Triggers™ Instrument in Predicting Postoperative Pressure Ulcer Risk

Hospital acquired pressure ulcers continue to pose a significant health problem in the US, affecting up to 3 million adults in acute care facilities at a cost of up to $11 billion annually. Surgical patients are at elevated risk for pressure ulcer development due to a combination of physiological, non-physiological, and surgical/anesthesia related factors.

Exploration of the Scott Triggers™ Instrument in Predicting Postoperative Pressure Ulcer Risk in the On-Pump Cardiovascular Surgery Population

Hospital acquired pressure ulcers continue to pose a significant health problem in the US, affecting up to 3 million adults at a cost of up to $11 billion annually. Postoperative pressure ulcer (PPU) rates are as high as 66%, with the incidence rates in cardiovascular (CV) surgical patients ranging as high as 50%.

Identification & Prevention of Pressure Ulcers Originating During Perioperative Care

Existing literature suggests that hospital operating rooms contribute significantly to hospital-acquired pressure ulcer development (Connor, Sledge, Bryant-Wiersema, Stamm, & Potter, 2010). It was found that there was no single instrument that has been consistently utilized as a predictive tool for pressure ulcers specifically in the perioperative environment. In order to combat these gaps, a project team was formed.

The cost-effectiveness of a patient centred pressure ulcer prevention care bundle: Findings from the INTACT cluster randomised trial

BackgroundPressure ulcers are serious, avoidable, costly and common adverse outcomes of healthcare. ObjectivesTo evaluate the cost-effectiveness of a patient-centred pressure ulcer prevention care bundle compared to standard care. DesignCost-effectiveness and cost-benefit analyses of pressure ulcer prevention performed from the health system perspective using data collected alongside a cluster-randomised trial. SettingsEight tertiary hospitals in Australia. ParticipantsAdult patients receiving either a patient-centred pressure ulcer prevention care bundle (n=799) or standard care (n=799). MethodsDirect costs related to the intervention and preventative strategies were collected from trial data and supplemented by micro-costing data on patient turning and skin care from a 4-week substudy (n=317). The time horizon for the economic evaluation matched the trial duration, with the endpoint being diagnosis of a new pressure ulcer, hospital discharge/transfer or 28days; whichever occurred first. For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided, estimated using a two-stage cluster-adjusted non-parametric bootstrap method. The cost-benefit analysis estimated net monetary benefit, which considered both the costs of prevention and any difference in length of stay. All costs are reported in AU$(2015). ResultsThe care bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. In the cost-effectiveness analysis, the care bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. This estimate is highly uncertain. Length of stay was unexpectedly higher in the care bundle group. In a cost-benefit analysis which considered length of stay, the net monetary benefit for the care bundle was estimated to be −$2320 (95%CI −$3900, −$1175) per patient, suggesting the care bundle was not a cost-effective use of resources. ConclusionsA pressure ulcer prevention care bundle consisting of multicomponent nurse training and patient education may promote best practice nursing care but may not be cost-effective in preventing hospital acquired pressure ulcer.

A Novel System to Tackle Hospital Acquired Pressure Ulcer Patients

A Novel System to Tackle Hospital Acquired Pressure Ulcer Patients

Prevention of Tracheostomy-Related Hospital-Acquired Pressure Ulcers.

Objective To determine if standardization of perioperative tracheostomy care procedures decreased the incidence of hospital-acquired tracheostomy-related pressure ulcers. Methods All patients at least 18 years old who underwent placement of a tracheostomy tube in the operating room from July 1, 2014, through June 30, 2015, were cared for postoperatively through an institutionally adopted quality improvement protocol. This included 4 elements: (1) placement of a hydrocolloid dressing underneath the tracheostomy flange in the postoperative period, (2) removal of plate sutures within 7 days of the tracheostomy procedure, (3) placement of a polyurethane foam dressing after suture removal, and (4) neutral positioning of the head. One year after the bundle was initiated, a retrospective analysis was performed to compare the percentage of tracheostomy patients who developed pressure ulcers versus the preintervention period. Results The incidence of tracheostomy-related pressure ulcers decreased from 20 of 183 tracheostomies (10.93%) prior to use of the standardized protocol to 2 of 155 tracheostomies (1.29%). Chi-square analysis showed a significant difference between the groups, with a P value of .0003. Discussion Adoption of this care bundle at our institution resulted in a significant reduction in the incidence of hospital-acquired tracheostomy-related pressure ulcers. The impact of any single intervention within our protocol was not assessed and could be an area of further investigation. Implications for Practice Adoption of a standardized posttracheostomy care bundle at the institution level may result in the improved care of patients with tracheostomies and specifically may reduce the incidence of pressure ulcers.

The Effectiveness of the Braden Scale as a Tool for Identifying Nutrition Risk

Pressure injuries are a global problem affecting approximately 2.5 million patients per year. These pressure injuries can drastically impact the patients’ quality of life, with increased pain and infection 1 Lyder C. Wang Y. Metersky M. et al. Hospital-acquired pressure ulcers: Results from the national medicare patient safety monitoring system study. J Am Geriatr Soc. 2012; 60: 1603-1608 Crossref PubMed Scopus (249) Google Scholar as well as increased costs to treat. The cost to treat a pressure injury, on average, is $20,900 to $151,700, depending on the severity and extent of the ulcer, and each pressure injury is thought to add approximately $43,180 to the cost of a patient’s hospital stay. 2 US Department of Health Services Agency for Healthcare Research and Quality. Are we ready for change? 2014. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html. Accessed November 15, 2016. Google Scholar These injuries also have been linked to increased mortality, with approximately 60,000 yearly patient deaths in the United States from complications of pressure injuries. 2 US Department of Health Services Agency for Healthcare Research and Quality. Are we ready for change? 2014. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html. Accessed November 15, 2016. Google Scholar However, with the correct identification of risk and prompt intervention, they are most often preventable.

Best Practices for Pressure Ulcer Prevention in the Burn Center.

The State of Pennsylvania Hospital Engagement Network, in collaboration with a hospital system in Southwestern Pennsylvania, established a goal of reducing hospital-acquired pressure ulcers by 20%. A 6-month unfavorable trend of nurse-sensitive clinical indicators called for immediate process improvement. A retrospective chart review resulted in identification of predominant risk factors placing the burn patient at high risk for pressure ulcer formation. Implementations of pressure ulcer prevention measures were inconsistent. Nurses demonstrated varied levels of knowledge about products used for prevention. It became imperative to examine processes within the unit and provide nursing with education, access to skin care supplies, and advanced skin/wound care products for maintaining skin integrity. Creation of evidence-based guidelines was necessary to improve patient outcomes. A collaborative team approach influenced nursing and physician awareness of pressure ulcer risk. Evidence-based prevention guidelines were developed, and consistency in early intervention was achieved, supporting our culture of safety. A change in interprofessional collaborative practice and positive trend in pressure ulcer incidence data supports the success of our program.

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.

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit.

In critically ill patients, prevention of pressure ulcers is a challenge because of the high risk for multiple comorbid conditions, immobility, hemodynamic instability, and increased use of medical devices. To compare the difference in incidence rates of hospital-acquired pressure ulcers (HAPUs) in critically ill patients between those treated with usual preventive care and a 5-layered soft silicone foam dressing versus a control group receiving usual care. Secondary goals were to examine risk factors for HAPUs in critically ill patients and to explicate cost savings related to prevention of pressure ulcers. A prospective, randomized controlled trial in the intensive care units at a 569-bed, level II trauma hospital. All 366 participants received standard pressure ulcer prevention; 184 were randomized to have a 5-layered soft silicone foam dressing applied to the sacrum (intervention group) and 182 to receive usual care (control group). The incidence rate of HAPUs was significantly less in patients treated with the foam dressing than in the control group (0.7% vs 5.9%, P = .01). Time to injury survival analysis (Cox proportional hazard models) revealed the intervention group had 88% reduced risk of HAPU development (hazard ratio, 0.12 [95% CI, 0.02-0.98], P = .048). Use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant benefit in reducing the incidence rate and severity of HAPUs in intensive care patients. This novel, cost-effective method can reduce HAPU incidence in critically ill patients.

Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality.

BackgroundTime trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated.MethodsQuarterly unit-level nursing data in 2004–2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed models were used to examine the associations between nurse staffing and patient outcomes at trend and seasonal levels.ResultsAt trend level, both staffing variables were inversely associated with all outcomes (p < 0.001); at seasonal level, total HPPD was inversely associated (higher staffing related to lower event rate) with all outcomes (p < 0.001) while RN skill-mix was positively associated (higher staffing related to higher event rate) with fall rate (p < 0.001) and pressure ulcer rate (p = 0.03). It was found that total HPPD tended to be lower and RN skill-mix tended to be higher in Quarter 1 (January-March) when falls and pressure ulcers were more likely to happen.ConclusionsBy aggregating data across units we were able to detect associations between nurse staffing and patient outcomes at both trend and seasonal levels. More rigorous research is needed to study the underlying mechanism of these associations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12912-016-0181-3) contains supplementary material, which is available to authorized users.

Effectiveness of Pressure Ulcer Prevention Strategies for Adult Patients in Intensive Care Units: A Systematic Review.

Pressure ulcers are associated with substantial health burden, but could be preventable. Hospital-acquired pressure ulcers (HAPUs) prevention has become a priority for all healthcare settings, as it is considered a sign of quality of care providing. Intensive care unit (ICU) patients are at higher risk for HAPUs development. Despite the availability of published prevention strategies, there is a little evidence about which strategies can be safely integrated into routine standard care and have an impact on HAPUs prevention. The aim was to synthesize the best available evidence regarding the effectiveness of single strategies designed to reduce the incidence and prevalence of HAPUs development in ICUs. The search strategy was designed to retrieve studies published in English across CINAHL, Medline, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Mednar between 2000 and 2015. All adult ICU participants were aged 18 years or over. This review included randomized controlled trials, quasi-experimental and comparative studies. The studies that were selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical-appraisal instruments. The review included 25 studies, and the meta-analysis revealed a statistically significant effect of a silicon foam dressing strategy in reducing HAPUs incidence (effect size = 4.62; 95% CI: 0.05-0.29; p < .00001, effect size = 4.50; 95% CI: 0.05-0.31; p = .00001, respectively) in critically ill patients. Evidence of the effectiveness of nutrition, skin-care regimen, positioning and repositioning schedule, support surfaces, and the role of education in prevention of HAPUs development in the ICU was limited, which precludes strong conclusions. The review provides an evidence-based guide to future priorities for clinical practice. In particular, a silicone foam dressing has positive impact in reducing sacrum and heel HAPUs incidence in the ICU.