Pressure Ulcer Staging Research Articles

Relationship between Pressure Ulcers in Elderly People and Physiological Indices of the Skin.

This study examined the relationship between skin physiological indices and pressure ulcers in elderly people. The subjects were 55 bedridden elderly Japanese patients with a median age of 85 years. The following parame-ters were measured using non-invasive devices: skin surface temperature, moisture content in the stratum corneum, moisture content in the dermis, transepidermal water loss as an index of skin barrier function, skin erythema and skin elasticity. The sacral and 2 heel areas were observed as sites predisposed to pressure ulcers. Within one month after measuring the skin physiological indices, we confirmed pressure ulcers of National Pressure Ulcer Advisory Panel classification Stage II or worse based on medical records. Among the 55 patients, 4 (7.3%) prospectively developed a total of 5 pressure ulcers within 16 days. Only the skin erythema score was significantly higher with than without pressure ulcers (p < 0.001). We performed a binary logistic regression analysis and confirmed a significant relationship between pressure-ulcer development and the level of erythema (odds ratio = 1.026; 95% confidence interval: 1.011-1.042). Skin erythema increased before the development of pressure ulcers. Taken together, our results show that the high skin erythema score can be a predictive indicator of pressure ulcers.

Characteristics of Hospital Acquired Pressure Ulcer and Factors Affecting Its Development: A Retrospective Study.

BackgroundWorldwide, pressure ulcers (PUs) have been implicated in costing billions annually, with 60,000 deaths out of 2.5 million hospitalized patients resulting from complications related to PU. The prevention of PU reduces the incidence of other illnesses, decreases the financial costs, and improves the quality of life for patients. We aimed to identify the most influential factors that increased the risk of developing PUs among hospitalized patients at a university hospital according to the Waterlow scale.MethodsData were collected retrospectively from patients who developed PUs between January 2016 and December 2018 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, and were evaluated using the Waterlow PU risk assessment tool. The analysis was performed using the Statistical Package for Social Science (SPSS), version 23.0 (IBM, Armonk, NY).ResultsA total of 272 cases were included in this study. The highest number of cases (n = 83, 30.5%) belonged to the age group of 50 to 64 years. The majority of patients had stage 2 PUs (165, 60.7%). The most frequent location of PU was the “back” (97, 35.7%). A history of undergoing major surgery was significantly associated with a higher stage of PU (p = 0.040). The mean Waterlow PU score for all cases was 27.19 ± 13.143. There was a moderate positive correlation between the neurological deficit score and the Waterlow PU score (correlation coefficient: 0.447, p < 0.001). Multinomial logistic regression analysis revealed that increasing age is a significant predictive factor for developing higher stages of PUs (p = 0.046).ConclusionMajor surgery, neurological deficit, low hemoglobin level, and increasing age were strong predictors for developing higher stages of PU. Therefore, healthcare contributors should consider these risks when applying a comprehensive PU management plan.

A Comparative Study Between Two Support Surfaces for Pressure Ulcer Prevention and Healing in ICU Patients.

ObjectiveThe aim of this research was to compare the effectiveness of two mattresses used in intensive care unit (ICU) high-risk patients in terms of pressure ulcers (PUs) prevention and healing.Materials and MethodsThe studied sample consisted of 70 consecutive patients aged 18 to 65 years hospitalized in two ICUs of a general hospital in Athens, Greece. Virtuoso Mattress System (LINET, Slaný, Czech Republic) was used in 35 patients, and standard memory foam mattress was used in the rest of participants. Patients were firstly assessed on enrollment and then every 72 hours in order to record the appearance or not of PUs, location of PUs, and stage of PUs, with the maximum follow-up not exceeding the 21 days. A number of clinical and biochemical factors, medical treatment, and vital signs were also recorded at each time point.ResultsOf the 70 patients, 40 (57.1%) were men, and the mean ± standard deviation age of the sample was 46.1 ± 14.5 years. The most common area of PUs was the buttocks (34.3%) followed by the shoulders (22.3%), with no statistically significant difference detected between the two groups. Moreover, the proportion of patients having PUs at stage 2 or higher was 23.8% on the third day after admission and 61.1% on the sixth day, with no difference detected between the two groups. Cox proportional hazard model revealed that the Virtuoso mattress was associated with almost 56% lower risk of developing PUs compared with standard foam mattress (HR [95% CI]: 0.44 [0.20-0.93]). The percentage of patients healed using the Virtuoso mattress was significantly lower compared with the standard foam mattress at all time points, with the results reaching statistical significance only on the 12th day after admission (7.7% vs. 66.7%; p < 0.05).ConclusionsThe Virtuoso mattress seems to be more effective compared with standard foam mattresses in the prevention of PUs, whereas the standard foam mattresses are more effective in PU healing process.

Nursing Effects of Medical Treatment Combination on Patients at High Risk of Developing Pressure Ulcers at Rural Homes

Objective: To explore the nursing effects of medical treatment combination on patients at high risk of developing pressure ulcers at rural homes. Methods: From January 2018 to December 2018, 86 patients at high risk of developing pressure ulcers at rural homes who were in Wenjiang Hospital were randomly divided into a control group and an observed group. The control group received the routine publicity and education and visiting, while the observed group adopted the cooperative nursing model of medical treatment combination. Then compare the healing status and nursing satisfaction of the two groups. Results: Of the 43 patients with pressure ulcers in the observed group, 18 had been in the second stage of pressure ulcers and 16 had been healed; 14 had been in the third stage of pressure ulcers and 8 had been healed; 11 had been in the fourth stage of pressure ulcers and 5 had been healed. The nursing satisfaction of the patients in the observed group was 95.35%. Conclusion: Conducting medical treatment combination on patients at high risk of developing pressure ulcers at rural homes can effectively improve the patients’ and their families’ awareness of pressure ulcer nursing, standardize their nursing behaviour, help recover the patients themselves and promote the patients’ satisfaction.

Prevalence of pressure ulcers in hospitalized adult patients in Bursa, Turkey: A multicentre, point prevalence study.

Pressure ulcers (PUs), which are preventable complications, increase the cost of health care and the risk of prolonged hospital stay, as well as morbidity and mortality. In this study, we aimed to describe the prevalence, clinical features, and risk factors for PUs among hospitalized patients. This study was cross-sectional and conducted over a single day in all the care units. Data were recorded on a patient observation form that included demographic data, diagnosis of admission to the hospital or intensive care unit (ICU), comorbidity and chronic diseases, location, stage of PU, and Braden Scale score. Acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma score (GCS), PaO2 /FiO2 ratio, and albumin level were recorded for ICU patients. A total of 1548 adult patients participated in the study. Of these patients, 177 (11.43%) had PU. The patients with PU had more advanced age, lower body mass index (BMI), and longer duration of hospital and ICU stay (for all P = .001). Evaluation of PU in the first 24 hours after hospital admission and the last PU evaluation time also showed a significant effect (both P = .001). Braden Scale score less than or equal to 13 in the first evaluation after hospital admission increased the risk of PU. Albumin was 2.78 ± 0.57 gm/dL in ICU patients, and albumin level was significantly lower in patients with PU (P = .001). PUs were located mainly in the sacrum (47.59%) and were classified as stage II (42.76%) for all patients. The prevalence of PU is related to the age and severity of patient clinical status, as predicted by the Braden Scale score and APACHE II score, and length of hospital and ICU stay. Low albumin level is also related to development of PUs in ICU patients.

People with non‐blanchable erythema are at higher risk of pressure ulcers

Pressure ulcers, also known as bed sores, are injury to the skin mainly caused by prolonged pressure, for example in someone who is bedridden. Pressure ulcers occur in 470 to 3,210 per 10,000 patients in hospitals in the U.K., U.S.A., and Canada. Their severity is graded from stage 1 (the least severe) to stage 4 (the most severe). For patients and carers, it is important to know what normal skin is and to regularly check skin changes over the common places where pressure ulcers may appear (e.g. the bottom, heels, and lower back). Non‐blanching erythema – skin redness that does not turn white when pressed – is an important skin change. This study, undertaken by researchers from the University of Manchester and University of Liverpool, U.K., aimed to find out whether people with non‐blanching erythema are more likely to develop pressure ulcers in future than those without non‐blanching erythema. The authors used systematic review and individual‐level data analysis methods to summarise evidence from thirteen studies (with 68,077 people), and to analyse individual‐level data of 3,223 patients. Their analysis showed that people with non‐blanchable erythema had 2.72 times the odds of developing a new pressure ulcer of Stage 2 or above within 28 days, compared with those without non‐blanchable erythema. This means that if 73 people per 1,000 without non‐blanchable erythema develop new pressure ulcers of Stage 2+ within 28 days, 176 people per 1,000 with non‐blanchable erythema will probably develop new ulcers. The authors conclude that people with non‐blanching erythema are more likely to develop new pressure ulcers of Stage 2 or above within 28 days, than people without non‐blanching erythema. It is important for medical staff to identify non‐blanchable erythema and to intervene appropriately to prevent pressure ulcers. This summary relates to the study: Nonblanchable erythema for predicting pressure ulcer development: a systematic review with an individual participant data meta‐analysis

Hospital-Acquired Conditions after Liver Transplantation

Hospital-acquired conditions (HACs) are used to define hospital performance measures. Patient comorbidity may influence HAC development. The National Inpatient Sample database was used to investigate HACs for the patients who underwent liver transplantation. Multivariate analysis was used to identify HAC risk factors. We found a total of 13,816 patients who underwent liver transplantation during 2002-2014. Of these, 330 (2.4%) had a report of HACs. Most frequent HACs were vascular catheter-associated infection [220 (1.6%)], falls and trauma [66 (0.5%), catheter-associated UTI [24 (0.2%)], and pressure ulcer stage III/IV [22 (0.2%)]. Factors correlating with HACs included extreme loss function (AOR: 52.13, P < 0.01) and major loss function (AOR: 8.11, P = 0.04), hepatopulmonary syndrome (AOR: 3.39, P = 0.02), portal hypertension (AOR: 1.49, P = 0.02), and hospitalization length of stay before transplant (AOR: 1.01, P < 0.01). The rate of HACs for liver transplantation is three times higher than the reported overall rate of HACs for GI procedures. Multiple patient factors are associated with HACs, and HACs may not be a reliable measure to evaluate hospital performance. Vascular catheter-associated infection is the most common HAC after liver transplantation.

Effectiveness of a Pressure Ulcer Prevention Package (PUPP) for Patients Admitted in Intensive Care Units: An Experimental Study

Many critically ill patients admitted in ICUs sedated on mechanical ventilation are unable to change the position themselves. Therefore, these patients are at high risk of impaired skin integrity that leads to development of pressure ulcers. This study assessed the effectiveness of pressure ulcer prevention package in reducing the incidences of pressure ulcers among patients in ICUs. In this experimental design pre-test post-test control group study, 70 patients 35 each in experimental and control group from different ICUs of Dr RML Hospital, New Delhi were randomly allocated into two groups i.e. experimental and control groups. Experimental group received the intervention of pressure ulcer prevention package and the control group received routine skin care. Demographic and clinical data were collected by using demographic pro'Agrave;le tool, standardised skin assessment tool and pressure ulcer staging tool. All the subjects were followed every third day from admission to discharge, death and up to a maximum 20 days. Data were analysed using STATA 11.1 with the level of signi'Agrave;cance at p'lt;0.05. Descriptive and inferential statistics were used. The sacrum and then heels were the most common areas of pressure ulcers among ICU patients. Pressure ulcer prevention package was signi'Agrave;cantly effective (p'lt; 0.001) to delay the pressure ulcers-related adverse events among patients of experimental group. Pressure ulcers-related adverse events were developed earlier in control group i.e. 14 percent in experimental and 41 percent in control group. Number of pressure ulcers development were signi'Agrave;cantly (p'lt;0.001) lower in experimental group (08/35) compared to control group (20/35). The experimental group had signi'Agrave; cantly less Stage I and Stage II pressure ulcers development compared to control group (p'lt;0.001). Pressure ulcers prevention package was found to be signi'Agrave;cantly effective to reduce incidences, severity and total number of pressure ulcers among patients admitted in ICUs.

Time-to-treatment is a risk factor for the development of pressure ulcers in elderly patients with fractures of the pelvis and acetabulum

IntroductionFractures of the pelvis and acetabulum are associated with pain and immobilization and, hence, pose the risk of developing a pressure ulcer - especially in elderly patients. In the literature, information on risk factors for the occurrence of pressure ulcers related to geriatric pelvic or acetabulum fractures is missing. MethodsConsecutive in-hospital patients aged 55 years or older treated for closed pelvis and/or acetabulum fractures between 2013 and 2017 were retrospectively identified from an institutional prospective database. Epidemiologic characteristics and patient specifics with special focus on the time from admission to treatment, duration of hospitalization and comorbidities were retrospectively assessed by chart review. ResultsDuring the evaluated interval, 407 patients with isolated fractures of the pelvis or acetabulum (mean age 78 years, range 55 to 101 years, 69,3% female) were treated. A new pressure ulcer that developed during the hospitalization was observed in 46/407 patients (11.3%). This included pressure ulcers of stage 1 in 18/46 cases (39%), stage 2 in 24/46 cases (52%), and stage 3 in 4/46 cases (9%). No stage 4 ulcers were seen in this cohort. The mean duration of hospitalization was longer in patients with a pressure ulcer (25 days, SD 17) than in patients with no ulcers (12 days, SD 9; p < .001). Patients who developed a pressure ulcer, had waited significantly longer for treatment of their pelvis/acetabulum fracture when compared to patients without an ulcer (5 days, SD 5 vs. 3 days SD 4, p = =.001). A logistic regression analysis confirmed “time to treatment” as an independent risk factor for the occurrence of a pressure ulcer during hospitalization. In an analysis adjusted for the confounders age, male gender, diabetes and malignancy, the odds ratio to develop a pressure ulcer remained 1.10 (CI 1.03 to 1.19; c-value = 0.774, p = .008) for each day of waiting treatment. Conclusion“Time to treatment” is an independent risk factor for the occurrence of a pressure ulcer during hospitalization after a pelvis/acetabulum fracture in elderly patients. Each day of waiting treatment increases the risk of developing a pressure ulcer by 10%.

Non-invasive detection of local tissue responses to predict pressure ulcer development in mouse models

The development of pressure ulcers is associated with four different pathways: ischemia, ischemia-reperfusion injury, impaired interstitial fluid flow and lymphatic drainage, and cell deformation. For prediction of pressure ulcer development, it is important to detect the tissue response involved in the pathways at the molecular level. However, non-invasive techniques for detecting this tissue response are not available. This study aimed to demonstrate that the secretion of the candidate marker proteins in pressure-loaded mouse skin can be detected by skin blotting, and to propose a novel direct skin assessment method for predicting pressure ulcer development. We created three different tissue damage models: early stage pressure ulcers, blanchable erythema and intact skin. We confirmed the pathways involved in the pressure ulcer development by histological analyses in the pressure ulcer model. Interleukin-1α (IL-1α), vascular endothelial growth factor C (VEGF-C) and heat shock protein 90α (HSP90α) were expressed in the pressure ulcer model at a significantly different level compared to the blanchable erythema or intact skin during the time course. Detecting the secretion of these novel biomarkers by skin blotting can be a useful method for non-invasive prediction of pressure ulcer development.

1423. Antibiotic Utilization and Outcomes in Patients with Sacral Osteomyelitis and Decubitus Ulcers

BackgroundOsteomyelitis is a common complication of advanced stage pressure ulcers and known to be associated with increased mortality, length of stay (LOS), and treatment costs. However, limited data and lack of guidelines regarding appropriate diagnosis and treatment result in variability in management. We sought to investigate whether microbiology data are associated with reduced antibiotic utilization in patients with osteomyelitis secondary to decubitus ulcers.MethodsThis retrospective cohort study included hospitalized patients from 2007 to 2015 with an advanced stage (IV or unstageable) sacral decubitus ulcer and clinical concern for osteomyelitis. The exposure group was those who underwent tissue culture (superficial swab, deep bedside or surgical tissue, or bone biopsy). The primary outcome was antibiotic days of therapy (DOT). Additional secondary outcomes including clinical characteristics at presentation, LOS, readmission rates, and antibiotic-related complications were evaluated using Fisher’s exact or Wilcoxon-Mann–Whitney test for continuous variables.ResultsA total of 220 cases of advanced-stage decubitus ulcer with clinical concern for osteomyelitis were identified. Data abstracted from 40 cases show that tissue cultures were obtained in 22 (55%). Bacterial growth was identified from 100% of samples sent for culture. Antibiotic use prior to admission was the most significant predictor of failure to obtain tissue cultures (P = 0.0002). MRI was performed in 15% of abstracted cases, with radiographic evidence of osteomyelitis noted in 100%. Bone biopsy was performed in 4 cases; bone pathology was not sent in any of these instances. Median antibiotic DOT was 84 days in both groups. ConclusionIn cases of sacral osteomyelitis secondary to decubitus ulcers, antibiotic use prior to admission was inversely related to the likelihood of obtaining a tissue culture. When tissue cultures were obtained, they were uniformly positive; however, in our preliminary analysis of 40 cases, this did not appear to influence antibiotic utilization as determined by DOT. Bone biopsy was rarely performed, and when done, was not sent for pathology despite this being recognized as the gold standard in the diagnosis of osteomyelitis. Disclosures All authors: No reported disclosures.

Protein expressions of matrix metalloproteinase-9 and its inhibitor and their ratio changes in wound healing of patients with stages Ⅲ and Ⅳ pressure ulcers

Objective: To explore the expression levels of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) protein and the change of MMP-9/TIMP-1 ratio in wound exudates of patients with stages Ⅲ and Ⅳ pressure ulcers during wound healing. Methods: From July 2017 to July 2018, 30 patients with stage Ⅲ pressure ulcers [30 wounds, 16 males and 14 females, aged (65±10) years] and 34 patients with stage Ⅳ pressure ulcers [50 wounds, 17 males and 17 females, aged (65±9) years] admitted to Hebei General Hospital who met the inclusion criteria were enrolled in this prospective cohort study. According to the principle of wound treatment and the characteristics and needs of wound in different periods, individualized intervention measures were formulated for patients and appropriate dressings were selected. At the time of admission and on 7, 14, 21, 28 days of treatment, the healing of pressure ulcer wounds was evaluated by Pressure Ulcer Healing Scale. Afterwards, the wound exudate was collected at each time point to detect the expression levels of MMP-9 and TIMP-1 protein by enzyme-linked immunosorbent assay, and the MMP-9/TIMP-1 ratio was calculated. Data were processed with analysis of variance for repeated measurements of single group and linear trend test. Results: (1) There were significantly statistical differences in wound healing scores of patients with stages Ⅲ and Ⅳ pressure ulcers among the time of admission and on 7, 14, 21, 28 days of treatment within each stage (F=145.382, 153.234, P<0.01), and they all showed a gradually decreasing trend (F=170.466, 284.585, P<0.01). (2) At the time of admission and on 7, 14, 21, 28 days of treatment, the expression levels of MMP-9 protein in wound exudates of patients with stages Ⅲ and Ⅳ pressure ulcers were (171±104), (138±88), (110±70), (85±55), (62±41) ng/L and (193±107), (173±104), (139±83), (114±70), (89±56) ng/L, respectively. There were significantly statistical differences within each stage (F=58.007, 111.680, P<0.01), and they all showed a gradually decreasing trend (F=62.901, 134.628, P<0.01). At the time of admission and on 7, 14, 21, 28 days of treatment, the expression levels of TIMP-1 protein in wound exudates of patients with stages Ⅲ and Ⅳ pressure ulcers were (6.2±3.9), (5.6±3.4), (5.1±3.1), (4.4±2.5), (3.8±2.3) ng/L and (4.8±2.5), (4.7±2.6), (4.4±2.6), (4.6±2.7), (4.1±2.4) ng/L, respectively. There were significantly statistical differences within each stage (F=25.479, 7.778, P<0.01), and there was a gradually decreasing trend in stage Ⅲ (F=62.901, P<0.01) and a decreasing trend in stage Ⅳ (F=134.628, P<0.01). At the time of admission, the expression levels of MMP-9 and TIMP-1 in wound exudates of patients with stage Ⅲ pressure ulcers were similar to those of patients with stage Ⅳ pressure ulcers (t=-1.03, 1.47, P>0.05). (3) At the time of admission and on 7, 14, 21, 28 days of treatment, the MMP-9/TIMP-1 ratios in the wound exudates of patients with pressure ulcers of stages Ⅲ and Ⅳ were 30±13, 25±9, 22±9, 20±8, 17±6 and 43±19, 37±13, 32±10, 26±9, 22±9, respectively. There were significantly statistical differences within each stage (F=37.173, 97.191, P<0.01), and they all showed a gradually decreasing trend (F=54.183, 130.088, P<0.01). At the time of admission, the MMP-9/TIMP-1 ratio in wound exudates of patients with stage Ⅳ pressure ulcers was significantly higher than that of patients with stage Ⅲ pressure ulcers (t=-3.42, P<0.01). Conclusions: During the wound healing process of patients with stages Ⅲ and Ⅳ pressure ulcers, the expression levels of MMP-9 and TIMP-1 protein and the MMP-9/TIMP-1 ratio in wound exudates show a decreasing trend. The stage of wound healing can be predicted according to the expression level of MMP-9 protein and the MMP-9/TIMP-1 ratio.

Nonblanchable erythema for predicting pressure ulcer development: a systematic review with an individual participant data meta-analysis.

Empirical evidence is uncertain regarding the value of nonblanchable erythema in predicting the incidence of stage 2 (or more severe) pressure ulcers. To investigate whether nonblanchable erythema is an independent prognostic factor for pressure ulcer incidence using individual patient data. We performed an electronic database search in February 2017 to identify longitudinal studies that considered nonblanchable erythema for predicting pressure ulcer risk in any population. We collected individual participant data for the included studies, and assessed the risk of bias of these studies using the Quality In Prognosis Studies tool. We analysed individual participant data in Stata using mixed-effects logistic regression to investigate the association of interest. The certainty of evidence from individual participant data analysis was assessed using the Grades of Recommendation Assessment, Development and Evaluation. The study was registered with PROSPERO (CRD42017081151). From the 13 included studies (total 68077 participants) we had access to individual participant data from four (n = 3223), and 11·9% of participants (383 of 3223) developed new pressure ulcers of stage 2 or above within 28 days. Mixed-effects logistic regression showed that participants with nonblanchable erythema had higher odds of developing new pressure ulcers of stage 2 or above within 28 days of follow-up than those without nonblanchable erythema (multivariable association: n = 2684; odds ratio 2·72, 95% confidence interval 2·02-3·69; τ2 = 0; moderate-certainty evidence). This first prognostic factor review with individual-level data analysis in patients with pressure ulcers suggests that people with nonblanchable erythema are more likely to develop new pressure ulcers of stage 2 or above within 28 days than people without nonblanchable erythema. It is important to identify nonblanchable erythema in practice and to intervene appropriately to prevent pressure ulceration. What's already known about this topic? Pressure ulcer reduction is a high priority for healthcare systems. Regularly inspecting skin to identify skin abnormalities is one key practice for preventing ulceration. Nonblanchable erythema - discoloration of the skin that does not turn white when pressed - is one clinically important skin abnormality. Empirical evidence synthesized using conventional meta-analysis is uncertain regarding the value of nonblanchable erythema for predicting open pressure ulcer incidence; this is partly because the conventional technique has weakness in terms of pooling prognostic effects of different multivariable analyses across studies. What does this study add? This prognostic factor review used individual-level data analysis to overcome the limitations of the conventional meta-analysis technique. For the first time there is confirmatory and moderate-certainty evidence on the association of nonblanchable erythema with pressure ulcer incidence. People with nonblanchable erythema are more likely to develop new pressure ulcers of stage 2 or more severe within 28 days than people without nonblanchable erythema, regardless of their age, baseline pressure ulcer risk or received support surfaces.

Sacral Skin Temperature and Pressure Ulcer Development: A Descriptive Study

The purpose of this prospective, descriptive study was to examine the relationship between sacral skin temperature and PU development. Using convenience sampling methods, patients who were hospitalized in the tertiary intensive care unit (ICU) of the internal medicine department of a university hospital in İzmir, Turkey, between April and December 2015 were eligible to participate if they were ⟩18 years of age, had an expected hospital stay of at least 5 days, a Braden score ≤12, and were admitted without a PU. Demographic and clinical data collected included age, gender, body mass index, diagnosis, mattress type, length of follow-up (days), systolic and diastolic blood pressure, body temperature, hemoglobin level, sacral skin temperatures in the supine and lateral positions, room temperature, PU stage and duration, and Braden score. Temperature was measured the day of hospitalization as a baseline measurement (day 1) and once every day thereafter up to 22 days, until the patient did or did not develop a PU, died, was no longer undergoing position change, or was discharged. Sacral skin temperature was taken immediately after the patient was moved to a lateral position following 120 minutes of supine position (referred to as supine position sacral skin temperature measurement) and after 30 minutes in lateral position (referred to as lateral position sacral skin temperature measurement). Data were collected using paper-and-pencil questionnaires and entered into a software program for analysis. Descriptive statistics, Student's t test, one-way analysis of variance test, Pearson product-moment correlation analysis, and Spearman's rank-order correlation analysis were used for data analysis. Of the 37 patients who met the inclusion criteria and were monitored for at least 5 days, 21 (56.8%) developed PUs. No statistically significant difference in supine position sacral skin temperature on day 1 or day 5 was found between patients who did and did not develop a PU (36.90° C ± 0.29° C and 37.15° C ± 0.53° C, respectively, on day 1; t = -1.656, P = .112; and 37.37° C ± 0.53° C and 37.30° C ± 0.79° C, respectively, on day 5; t = 0.259, P = .798). Day 5 lateral position skin temperatures also did not differ significantly between the 2 groups (37.44° C ± 0.44° C and 37.31° C ± 0.75° C, respectively; t = 1.306, P = .621). A statistically significant difference was noted between mean sacral skin temperature in the supine position among patients ages 75 to 90 years compared with patients 38 to 64 years and 65 to 74 years (36.93° C ± 0.39° C; F = 13.221, P = .000) and with use of a viscoelastic mattress compared with an alternating pressure air mattress and continuous lateral rotation alternating pressure air mattress (37.85° C ± 0.54° C; F = 14.039, P = .000). No statistically significant differences in sacral skin temperatures were found for any of the of the other variables assessed. Sacral skin temperatures were not statistically different between ICU patients who did and did not develop a PU. Additional research may help increase understanding of the relationship between skin temperature and PU development.

Noninvasive staging of pressure ulcers using photoacoustic imaging

Ulcers including pressure ulcers and diabetic foot ulcers damage the skin and underlying tissue in people with compromised blood circulation. They are classified into four stages of severity and span from mild reddening of the skin to tissue damage and muscle/bone infections. Here, we used photoacoustic imaging as a noninvasive method for detecting early tissue damage that cannot be visually observed while also staging the disease using quantitative image analysis. We used a mouse model of pressure ulcers by implanting subdermal magnets in the dorsal flank and periodically applying an external magnet to the healed implant site. The magnet-induced pressure was applied in cycles, and the extent of ulceration was dictated by the number of cycles. We used both laser- and light-emitting diode (LED)-based photoacoustic imaging tools with 690 nm excitation to evaluate the change in photoacoustic signal and depth of injury. Using laser-based photoacoustic imaging system, we found a 4.4-fold increase in the photoacoustic intensity in stage I vs. baseline (no pressure). We also evaluated the depth of injury using photoacoustics. We measured a photoacoustic ulcer depth of 0.38 ± 0.09 mm, 0.74 ± 0.11 mm, 1.63 ± 0.4 mm, and 2.7 ± 0.31 mm (n = 4) for stages I-IV, respectively. The photoacoustic depth differences between each stage were significant (p < 0.05). We also used an LED-based photoacoustic imaging system to detect early stage (stage I) pressure ulcers and observed a 2.5-fold increase in photoacoustic signal. Importantly, we confirmed the capacity of this technique to detect dysregulated skin even before stage I ulcers have erupted. We also observed significant changes in photoacoustic intensity during healing suggesting that this approach can monitor therapy. These findings were confirmed with histology. These results suggest that this photoacoustic-based approach might have clinical value for monitoring skin diseases including pressure ulcers.

Nursing personnel’s knowledge regarding pressure sore management in a public hospital’s medical and surgical wards

Introduction: Despite the recent advances in ulcer treatment and management, and the immense advancements in technology, pressure ulcers are still a major challenge for nurses and doctors who are responsible for their management. Aim: The aim of the present study was to investigate the knowledge, practices and attitudes of nursing staff in a large public hospital regarding prevention and management of pressure ulcers. Methods: This study is a research cross-sectional study which involved all nursing staff (nurses and nursing assistants) working in medical and surgical wards of the General Hospital of Nikaia “St Panteleimon”. The questionnaire used for data collection has been developed by Gouda et al. (2014). The reliability of the questionnaire was high (Cronbach a=0.714) and the response rate was 76.7%. Statistical analysis was performed with the SPSS for Windows (21.00) statistical software. Results: The sample of the study consisted of 92 nurses aged 40.5(± 7.9) years. A total of 41 (44.6%) participants were nurse assistants, 33 (35.9%) had graduate from applied science universities, 14 (15.2%) had postgraduate degree and 4 (4.3%) had a university degree. The participants’ working experience was 15.1(± 9.1) years, while 45 (48.9%) nurses were working in surgical departments and 47 (51.1%) in medical ones. Of the total sample, twelve (13.3%) nurses have claimed that training seminars on prevention and management of pressure ulcers have been organized in the hospital that they are working. In a total of 27 questions, the correct answers given by the respondents were 18.59(±2.8) or 68.6% (±10.4%) with a minimum of 12 (44.4%) and a maximum of 25 (92.6%) correct answers. Participants with a higher level of education and those who had attended educational seminars [18.7(±2.8) versus 17(±2.6)] answered significantly more questions than those with a lower level of education (p &lt;0.05). Conclusions: The nursing staff working in the medical and surgical wards had moderate levels of knowledge and high level of knowledge for the definition and classification of pressure ulcers. It is proposed that clinical protocols be drawn up concerning the staging, prevention and management of pressure ulcers, as well as a more organized continuing training of nursing staff.

Assessing Pressure Ulcer Knowledge of General and Orthopedic Surgical Residents Using the Pieper Pressure Ulcer Knowledge Test

Objective To determine the knowledge of postgraduate and non-postgraduate general and orthopedic surgical residents regarding pressure ulcer (PU) prevention, staging and wound description. Study Design Cross sectional, descriptive survey. Place and Duration of Study Six major tertiary care hospitals in India, from Sep-2018 to Nov-2018. Methodology All consenting postgraduate and non-postgraduate general and orthopedic surgical residents were included in the study using convenience sampling. An adapted version of Pressure Ulcer Knowledge Test (PUKT) comprising of 47-true/false items was used as a research tool. For every correct response, 1 point was awarded. Whereas, an incorrect or NK response was scored as 0. All the data was entered and analyzed using SPSS version 21. Results A total of 126 trainees comprising 120 (95.23%) males and 6 (4.76%) females participated in the study. The average PUKT score obtained by the surgical residents was 30.2+3.7 (65.65%), thus indicating a “low” level of knowledge. Conclusion The current levels of knowledge regarding PU prevention among the surgical residents in our study was “low”. The authors recommend continuous education for PU prevention in a hospital care setting.

Improving the Healthcare Quality Measurement System Using Attribute Agreement Analysis Assessing the Presence and Stage of Pressure Ulcers

Measurement Systems Analysis has recently been used in healthcare service processes mainly to assess the accuracy and use of equipment and devices. However, thirty-seven percent of emergency department healthcare malpractice claims were related to diagnosis errors. Diagnosis is heavily dependent upon human assessment and decisions. The paper describes the application of a healthcare case study that applied Measurement Systems Analysis Attribute Agreement Analysis and Gage RR and 2) to demonstrate the usefulness of expanding gage R&R and attribute agreement analysis to human diagnosis in healthcare settings.

Topical Nifedipine for the Treatment of Pressure Ulcer: A Randomized, Placebo-Controlled Clinical Trial.

Effect of nifedipine on pressure ulcer (PU) healing has not been evaluated in the human subjects yet. In this study, the effect of topical application of nifedipine 3% ointment on PU healing in critically ill patients was investigated. This was a randomized, double-blind, placebo-controlled clinical. In this study, 200 patients with stage I or II PU according to 2-digit Stirling Pressure Ulcer Severity Scale were randomized to receive topical nifedipine 3% ointment or placebo twice daily for 14 days. Changes in the size and stage of the ulcers were considered as primary outcome of the study. The stage of the ulcers at baseline and on day 7 and day 14 of study was determined by using 2-digit stirling scale. In addition, the surface area of the wounds was estimated by multiplying width by length. In total, 83 patients in each group completed the study. The groups were matched for the baseline stage and size of PUs. Mean decrease in the stage of PU in the nifedipine group was significantly higher than the placebo group on day 7 (-1.71 vs. -0.16, respectively, P < 0.001) and day 14 (-0.78 vs. -0.09, respectively, P < 0.001). Furthermore, the mean decrease in the surface area of PU was significantly higher in the nifedipine group compared with the placebo group on day 7 (-1.44 vs. -0.32, respectively, P < 0.001) and day 14 (-2.51 vs. -0.24, respectively, P < 0.001) of study. Topical application of nifedipine 3% ointment for 14 days significantly improved the healing process of stage I or II PUs in critically ill patients.

Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting

ObjectiveDetermine the incidence and risk factors for pressure ulcers in a paediatric intensive care unit. Use the information gathered to develop preventive pressure ulcer care bundles. Research methodologyProspective cohort study using Braden Q Scale for Predicting Pressure Sore Risk and European Pressure Ulcer Advisory Panel Pressure Ulcer Staging tool. SettingGeneral paediatric intensive care unit in a tertiary level hospital between May and October 2017. ResultsSeventy-seven children were recruited. Most children were male (n = 42, 54.5%) and all nine children (11.7%) that developed a pressure ulcer were male. The main risk factor for developing a pressure ulcer was lack of physical activity. None of the children assessed as high or severe risk developed a pressure ulcer. Eight (89%) pressure ulcers were assessed as grade one. Seven pressure ulcers (77.8%) were on the facial and scalp area and all seven children were receiving airway support at the time the pressure ulcers developed. ConclusionIncidence of pressure ulcers was 11.7%, with the facial and scalp area the most common anatomical areas affected. Medical devices appeared to be the prime causative factor. Based on our data we have modified and launched the SSKIN care bundle for the paediatric intensive care unit setting.