Pressure Ulcer Prevention Care Research Articles

The effect of a pressure ulcer prevention care bundle on nursing workload costs

AimThis study investigated the effect of care under the guidance of a pressure ulcer prevention care bundle on pressure ulcer incidence rates and on nursing workload costs. Design, setting, and participantsThis prospective pre-post interventional study was conducted in an anesthesia and reanimation intensive care unit. The sample consisted of 16 nurses and 84 patients. MethodsThe study was conducted in two periods: (1) nursing workload of pre-care bundle period and (2) nursing workload of post-care bundle period. In the collection of data, 6 forms (the demographic data forms, the Braden scale, nurse information form, the care bundle follow-up form and nursing workload follow-up form) were administered. The main outcomes of the study; Pressure ulcer incidence rate was evaluated with Form V, and nursing workload costs were evaluated with Form VI. These forms were evaluated daily by the nurses. In the first period (15.09.2018–30.11.2018), pressure ulcer incidence rates and nursing workload costs were evaluated before training. Then, the researcher trained nurses on how to prevent pressure ulcers and use the care bundle. The care bundles components were risk assessment, skincare, activity, in-service training, nutrition, wetness/incontinence and support surface management, and keeping records. In the second period (01.12.2018–15.02.2019), pressure ulcer incidence rates and nursing workload costs were evaluated after the training. The outcomes of the two periods regarding the incidence of pressure ulcers and nursing workload costs were compared. ResultsThe pressure ulcer incidence rates before and after the care bundle were 22.1 and 13.0 per 100 patient-day, respectively. There was a decrease in pressure ulcer incidence rates after the care bundle, but it wasn't significant (p = 0.138). The total workload cost of pressure ulcer prevention was significantly lower after the care bundle than before (p = 0.001). ConclusionThe pressure ulcer incidence rates were lower after the care bundle than before, albeit insignificantly. The total pressure ulcer prevention workload costs were significantly lower after the care bundle than before. The reduction in pressure ulcer incidence and workload cost indicates that the use of care bundle is effective. Healthcare professionals in intensive care units should use a pressure ulcer prevention care bundle more often.

Development and Effectiveness of a Clinical Decision Support System for Pressure Ulcer Prevention Care Using Machine Learning: A Quasi-experimental Study.

This study was conducted to develop and evaluate the effectiveness of a clinical decision support system for pressure ulcer prevention on clinical (performance, visual discrimination ability, and decision-making ability) and cognitive (knowledge and attitude) workflow. After developing a clinical decision support system using machine learning, a quasi-experimental study was used. Data were collected between January and April 2020. Forty-nine RNs who met the inclusion criteria and worked at seven tertiary and five secondary hospitals participated. A clinical decision support system was provided to the intervention group during the same period. Differences in outcome variables between the two groups were analyzed using t tests. The level of pressure ulcer prevention nursing performance and visual differentiation ability of skin pressure and oral mucosa pressure ulcer showed significantly greater improvement in the experimental group compared with the control group, whereas clinical decision making did not differ significantly. A clinical decision support system using machine learning was partially successful in performance of skin pressure ulcer prevention, attitude, and visual differentiation ability for skin and oral mucosa pressure ulcer prevention. These findings indicated that a clinical decision support system using machine learning needs to be implemented for pressure ulcer prevention.

For people at risk of developing pressure ulcers, what are the effects of patient and lay carer pressure ulcer education and prevention care bundles?

For people at risk of developing pressure ulcers, what are the effects of patient and lay carer pressure ulcer education and prevention care bundles?

Patient and lay carer education for preventing pressure ulceration in at-risk populations.

Patient and lay carer education for preventing pressure ulceration in at-risk populations.

Development and Utilization of a Clinical Decision Support System Contents for Pressure Ulcer Prevention Care

Development and Utilization of a Clinical Decision Support System Contents for Pressure Ulcer Prevention Care

Patient expectations of pressure ulcer prevention in the NHS, healthcare demands and national policy: a critical commentary.

Preventive care was recently identified as a Government priority, which is likely to affect pressure ulcer (PU) preventive care in the NHS. Contemporary economic analyses of PU prevention interventions are undermined by factors including methodological challenges and poor inter-rater reliability of PU risk assessment tools. Healthcare demands on the NHS created by PU prevention remain unclear, although the burden is high, with litigation costs rising continuously. The poorly understood economics of PU prevention may create variation in practice. Patient expectations of PU prevention may be influenced by mainstream media, national awareness campaigns and the varied information and advice offered by professionals. Patient expectations and low levels of functional health literacy may create confusion and unrealistic expectations. This article critically examines the impact of recent changes in Government priorities related to PU prevention, considering the effects of healthcare demand, economics and patient expectations.

Using the SSKIN care bundle to prevent pressure ulcers in the intensive care unit.

Pressure ulcers develop when the skin and underlying tissues are subjected to pressure, friction and/or shear, and, in many cases, moisture. These factors lead to impaired blood supply and injury to the skin and underlying tissues. Patients being cared for in intensive care units are particularly at risk of pressure ulcers because they often lack the ability to change position independently. Also, their consciousness and sensory perception are impaired due to sedation and anaesthesia, diminished circulation and malnutrition. This article examines pressure ulcer prevention in this vulnerable group of patients and outlines the five-step SSKIN (surface, skin inspection, kinetics/keep moving, incontinence/moisture, nutrition/hydration) pressure ulcer prevention care bundle.

Pressure Ulcer Prevention Care Bundle: A Cross-sectional, Content Validation Study

This study was conducted to determine the content validity of a previously developed pressure ulcer prevention care bundle. A cross-sectional study was performed in a university hospital in Turkey among 95 nurses employed in 8 intensive care units (ICUs) who were invited to use and assess a care bundle based on pressure ulcer guidelines found in the literature and developed by researchers. The care bundle included 48 statements divided into 8 categories. Participants in the care bundle content validation completed 3 paper-and-pencil instruments: a nurse demographic information tool, an item-by-item content validation of the care bundle rated on a 4-point Likert scale, and an evaluation of the care bundle's pressure ulcer prevention capabilities using I agree, I do not agree responses to statements regarding comprehensiveness, ability to prevent pressure ulcers, feasibility, implementation, and complexity. Data were collected to a paper form and analyzed using descriptive statistics, mean scores, and the content validity index (CVI). Of a total of 95 potential nurse participants, 68 completed the survey instruments (62 [91.2%] women, overall average age 29.9 ± 5.7 years), for a response rate of 71.6%; 57 (83.8%) had bachelors degrees, 36 (52.9%) had between 5 and 10 years of experience, 24 (35.3%) had participated in a pressure ulcer education program, and 41 (69.3%) cared for patients with 1 to 2 pressure ulcers per week. The care bundle's overall mean content validation score was 3.9 ± 0.1; this was deemed valid and appropriate after minor wording modifications on 2 items. Nurses rated the care bundle as comprehensive, feasible, necessary, and helpful for making clinical decisions; 12 participants had concerns regarding its complexity and implementation. The care bundle may help nurses develop appropriate interventions for patients. Future research should include assessment using larger groups of nurses and construct validation studies.

A study on the nursing knowledge, attitude, and performance towards pressure ulcer prevention among nurses in Korea long-term care facilities.

This study aimed to investigate Korean nurses' level of knowledge, attitude, and performance of pressure ulcer prevention in long-term care facilities. A descriptive study was performed. Convenience sampling was used, and registered nurses were recruited from the attendees of a continuing education programme for nurses in long-term care facilities. A total of 282 participants (RN) completed the questionnaire. Data were collected from September to December 2015. Nurses participating in this study demonstrated a moderate level of knowledge of pressure ulcer prevention (60.1%) and exhibited positive attitudes towards pressure ulcer prevention (33.80 ± 2.48). Nurses regularly assessed the risk factors of pressure ulcers during the hospitalisation period for all patients in the hospital when performing pressure ulcer prevention care. However, the plan for preventive nursing care was not properly reviewed. It was also found that nurses did not consider changes in the patient's condition as important to why they had to change their nursing plans to prevent pressure ulcer. Therefore, this study suggested that appropriate guidelines, education programmes, and an environment that makes it possible to provide continuing education should be created for nurses to prevent pressure ulcers in Korea's long-term care facilities.

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.

Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial

BackgroundPressure ulcers cause suffering to patients and costs to society. Reducing pressure at the interface between the patient's body and the support surface is a valid clinical intervention for reducing the risk of pressure ulcers. However, studies have shown that knowledge of how to reduce pressure and shear and to prevent pressure ulcers is lacking. ObjectiveTo evaluate the effect of a pressure mapping system on pressure ulcer prevalence and incidence in a hospital setting. DesignPragmatic randomised controlled trial. SettingA geriatric/internal medical ward with 26 beds in a Swedish university hospital. Participants190 patients were recruited (intervention: n=91; control: n=99) over a period of 9 months. Patients were eligible if they were over 50 years old, admitted to the ward between Sunday 4pm and Friday 4pm, and expected to stay in the ward ≥3 days. InterventionThe continuous bedside pressure mapping system displays the patient's pressure points in real-time colour imagery showing how pressure is distributed at the body–mat interface. The system gives immediate feedback to staff about the patient's pressure points, facilitating preventive interventions related to repositioning. It was used from admittance to discharge from the ward (or 14 days at most). Both intervention and control groups received standard pressure ulcer prevention care. ResultsNo significant difference in the prevalence and incidence of pressure ulcers was shown between intervention and control groups. The prevalence of pressure ulcers in the intervention group was 24.2% on day 1 and 28.2% on day 14. In the control group the corresponding numbers were 18.2% and 23.8%. Seven of 69 patients (10.1%) in the intervention group and seven of 81 patients (8.6%) in the control group who had no pressure ulcers on admission developed category 1 and category 2 ulcers during their hospital stay. The incidence rate ratio between the intervention and control groups was 1.13 (95% CI: 0.34–3.79). ConclusionsThis study failed to demonstrate a beneficial effect of a pressure mapping system on pressure ulcer prevalence and incidence. However, the study could have increased staff awareness and focus on pressure ulcer prevention, thus affecting the prevalence and incidence of pressure ulcers in a positive way in both study groups. It is important to further investigate the experience of the multidisciplinary team and the patients regarding their use of the pressure mapping system, as well as strengths and weaknesses of the system.

Patients’ Perceptions of a Pressure Ulcer Prevention Care Bundle in Hospital: A Qualitative Descriptive Study to Guide Evidence‐Based Practice

Pressure ulcers place a significant burden on patients and hospitals. Our team developed and tested a pressure ulcer prevention care bundle (PUPCB) in a cluster randomized trial. As part of the process evaluation conducted alongside the trial, we explored patients' perceptions of the intervention. To identify patients' perceptions and experiences of a PUPCB in hospital. This qualitative descriptive study explored the perceptions of a subset of patients who participated in a trial testing the PUPCB across four intervention hospitals. A trained interviewer conducted semistructured interviews, which were digitally recorded, transcribed, and analyzed using thematic analysis. Nineteen patients were interviewed across the four hospitals. Three main themes emerged: (a) importance of personal contact in PUPCB delivery; (b) understanding pressure ulcer prevention (PUP) enhances participation; and (c) individual factors impact patients' engagement in PUP. The extent to which patients adopted the intervention appeared to be influenced by the complexity of education materials, compatibility with patients' existing knowledge and beliefs, and perceived advantage of the intervention; ability for human interaction; and patient-related facilitators and barriers to participating in PUP care. This study found patients accepted a PUPCB that encouraged participation in care, particularly as it involved personal and positive interactions with nurses and provision of information that was easy to understand and resonated with patients.

Process evaluation of a cluster-randomised trial testing a pressure ulcer prevention care bundle: a mixed-methods study

BackgroundAs pressure ulcers contribute to significant patient burden and increased health care costs, their prevention is a clinical priority. Our team developed and tested a complex intervention, a pressure ulcer prevention care bundle promoting patient participation in care, in a cluster-randomised trial. The UK Medical Research Council recommends process evaluation of complex interventions to provide insight into why they work or fail and how they might be improved. This study aimed to evaluate processes underpinning implementation of the intervention and explore end-users’ perceptions of it, in order to give a deeper understanding of its effects.MethodsA pre-specified, mixed-methods process evaluation was conducted as an adjunct to the main trial, guided by a framework for process evaluation of cluster-randomised trials. Data was collected across eight Australian hospitals but mainly focused on the four intervention hospitals. Quantitative and qualitative data were collected across the evaluation domains: recruitment, reach, intervention delivery and response to intervention, at both cluster and individual patient level. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed using thematic analysis.ResultsIn the context of the main trial, which found a 42% reduction in risk of pressure ulcer with the intervention that was not significant after adjusting for clustering and covariates, this process evaluation provides important insights. Recruitment and reach among clusters and individuals was high, indicating that patients, nurses and hospitals are willing to engage with a pressure ulcer prevention care bundle. Of 799 intervention patients in the trial, 96.7% received the intervention, which took under 10 min to deliver. Patients and nurses accepted the care bundle, recognising benefits to it and describing how it enabled participation in pressure ulcer prevention (PUP) care.ConclusionsThis process evaluation found no major failures relating to implementation of the intervention. The care bundle was found to be easy to understand and deliver, and it reached a large proportion of the target population and was found to be acceptable to patients and nurses; therefore, it may be an effective way of engaging patients in their pressure ulcer prevention care and promoting evidence-based practise.

Pressure ulcers in critically III patients in Saudi Arabia: An opportunity for collaborative research on an ugly disease

Pressure ulcers are common in critically ill patients and are associated with increased morbidity, mortality and cost. Studies on pressure ulcer prevention and management indicate the need for multifaceted care and multidisciplinary involvement. However, there are obvious deficits in pressure ulcer prevention efforts and care worldwide. Studies on pressure ulcers acquired in the intensive care unit (ICU) in Saudi Arabia are scarce. We propose a study to determine in Saudi ICUs pressure ulcer prevalence, risk factors, management and outcomes to improve the related care processes.

Improvement of pressure ulcer prevention care in private for-profit residential care homes: an action research study.

BackgroundA need exits to develop a protocol for preventing pressure ulcers (PUs) in private for-profit nursing homes in Hong Kong, where the incidence of PUs is relatively high and which have high proportion of non-professional care staff. The implementation of such protocol would involve changes in the practice of care, likely evoking feelings of fear and uncertainty that may become a barrier to staff adherence. We thus adopted the Systems Model of Action Research in this study to manage the process of change for improving PU prevention care and to develop a pressure ulcer prevention protocol for private for-profit nursing homes.MethodsA total of 474 residents and care staff who were health workers, personal care workers, and/or nurses from four private, for-profit nursing homes in Hong Kong participated in this study. Three cyclic stages and steps, namely, unfreezing (planning), changing (action), and refreezing (results) were carried out. During each cycle, focus group interviews, field observations of the care staff’s practices and inspections of the skin of the residents for pressure ulcers were conducted to evaluate the implementation of the protocol. Qualitative content analysis was adopted to analyse the data. The data and methodological triangulation used in this study increased the credibility and validity of the results.ResultsThe following nine themes emerged from this study: prevention practices after the occurrence of PUs, the improper use of pressure ulcer prevention materials, non-compliance with several prevention practices, improper prevention practices, the perception that the preventive care was being performed correctly, inadequate readiness to use the risk assessment tool, an undesirable environment, the supplying of unfavorable resources, and various management styles in the homes with or without nurses. At the end of the third cycle, the changes that were identified included improved compliance with the revised risk assessment method, the timely and appropriate use of PU prevention materials, the empowering of staff to improve the quality of PU care, and improved home management.ConclusionThrough the action research approach, the care staff were empowered and their PU prevention care practices had improved, which contributed to the decreased incidence of pressure ulcers. A PU prevention protocol that was accepted by the staff was finally developed as the standard of care for such homes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0361-8) contains supplementary material, which is available to authorized users.

Nurses' perceptions of a pressure ulcer prevention care bundle: a qualitative descriptive study.

BackgroundPressure ulcer prevention is a critical patient safety indicator for acute care hospitals. An innovative pressure ulcer prevention care bundle targeting patient participation in their care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention care bundle intervention on clinical practice.MethodsThis qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention care bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the care bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis.ResultsEighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention care bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention care bundle; 3) Appreciating the positive aspects of patient participation in care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention care bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention care bundle implementation.ConclusionsOverall, nurses found the care bundle feasible and acceptable. They identified a number of benefits from the bundle, including improved communication, awareness and participation in pressure ulcer prevention care among patients and staff. However, nurses thought the care bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the bundle included facilitation through effective communication and dissemination of evidence about the care bundle; strong leadership and ability to influence staff behaviour; and simplicity of the care bundle.

ISQUA16-2368THE EFFECT OF A PATIENT CENTRED CARE BUNDLE INTERVENTION ON PRESSURE ULCER INCIDENCES (INTACT)

Hospital acquired pressure ulcers (HAPU) are a serious patient safety concern, resulting in poor patient outcomes and high healthcare costs. We developed a patient-centred pressure ulcer prevention care bundle (PUPCB) with input from patients, nurses and other health professionals. The objective of this study was to test the effectiveness of this PUPCB on incidence of HAPU in at-risk hospitalised patients. This cluster randomised trial recruited tertiary hospitals with >200 beds in three Australian states. Patients were eligible if they were: …

The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial

BackgroundHospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. ObjectiveTo evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. DesignPragmatic cluster randomised trial. SettingEight tertiary referral hospitals with >200 beds each in three Australian states. Participants1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. MethodsHospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients’ participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. ResultsFour clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported. ConclusionsAlthough the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.

Study protocol of a cluster randomized controlled trial evaluating the efficacy of a comprehensive pressure ulcer prevention programme for private for-profit nursing homes.

BackgroundBecause the demand for government-subsidized nursing homes in Hong Kong outstrips the supply, the number of for-profit private nursing homes has been increasing rapidly. However, the standard of care in such homes is always criticized. Pressure ulcers are a major long-term care issue that is closely associated with the quality of care delivered in nursing home settings. The aim of this study is to evaluate the effectiveness of a pressure ulcer prevention programme for residents in private for-profit nursing homes.Methods/designThis is a two-arm cluster randomized controlled trial with an estimated sample size of 1088 residents and 74 care staff from eight for-profit private nursing homes. Eligible nursing homes will be those classified as category A2 homes in the Enhanced Bought Place Scheme (EBPS), having a capacity of around 130–150 beds, and no structured PU prevention protocol and/or programmes in place. Care staff will be health workers, personal care workers, and nurses who are front-line staff providing direct care to residents. Eight nursing homes will be randomly assigned to either an experimental or control group. The experimental group will be provided with an intensive training programme and will be involved in the implementation of a 16-week pressure ulcer prevention protocol, while the control group will deliver the usual pressure ulcer prevention care. The study outcomes are the pressure ulcer prevention knowledge and skills of the care staff and the prevalence and incidence of pressure ulcers. Data on the knowledge and skills of care staff, and prevalence of pressure ulcer will be collected at the base line, and then at the 8th week and at completion of the implementation of the protocol. The assessment of the incidence of pressures will start from before the commencement of the intensive training course to the end of the implementation of the protocol.DiscussionIn view of the negative impact of pressure ulcers, it is important to have an effective and evidence-based pressure ulcer prevention programme to improve preventive care in private for-profit nursing homes. The programme will potentially improve the knowledge and skills of care staff on the prevention of pressure ulcers and also lead to a reduction in the development of pressure ulcers in nursing homes.Trial registrationThe Current Controlled Trial is NCT02270385, 18 October 2014.

​Patient and lay carer education for preventing pressure ulceration in at-risk populations

​Patient and lay carer education for preventing pressure ulceration in at-risk populations