Risk Of Developing Pressure Ulcers Research Articles

Pressure ulcer risk assessment in the ICU. Is it time for a more objective measure?

BackgroundThe Braden scale, one of the most widely used risk assessment tools is often criticized when used in the Intensive Care Unit. Most patients in the Intensive Care Unit are at risk of pressure ulcer development meaning that the Braden score will usually indicate high risk for these patients. This study set out to determine the correlation between Sub-Epidermal Moisture measurements and Braden scores among Intensive Care Unit patients. MethodsThis study employed an observational research design. Braden score was assessed on all study days (1–5), in addition to visual skin assessment and Sub-Epidermal Moisture measurements at the sacrum and heels. Sub-Epidermal Moisture measurements were categorised as low (<0.5), borderline abnormal (≥0.5), and high (≥0.8). Correlation was assessed between Sub-Epidermal Moisture levels and Braden scores. ResultsA total of 53 participants were recruited. The median (interquartile range) baseline Braden score was 9 (9–10) and 81 % (n = 43) of participants were at very high/high risk of pressure ulcer development. Braden scores remained relatively constant over time with little fluctuation in scores. 19 % (n = 10) of patients had normal (<0.5) Sub-Epidermal Moisture delta measurements on enrolment, and all developed abnormal measurements by day 2. There were no significant correlations between Braden scores and Sub-Epidermal Moisture measurements. ConclusionAlthough this was not its original intention, a missing link with the Braden scale is that it does not provide information on how patients are responding to the adverse effects of pressure and shear forces. Furthermore, in patients who are critically unwell, most patients are classified as being “at risk” of pressure ulcer development. Therefore, an objective measure of how patients are responding to pressure and shear forces at different anatomical areas is needed. Implications to clinical practiceSub-Epidermal Moisture measurements can offer more information, not only on identifying those who are at risk, but also how those patients are tolerating this risk at different anatomical sites.

Prediction Pressure Ulcers in High Care Unit Patients: Evaluating Risk Factors and Predictive Scale Using a Prospective Cross-Sectional Study.

Background The incidence of ulcer pressure in the high care unit (HCU) was relatively high and could be reliably predicted using tools such as the Norton and Jackson/Cubbin scales. However, other risk factors, such as age, gender, consciousness, systemic condition, duration of treatment, and use of restraint, may contribute to the occurrence of ulcer pressure. This study was conducted to analyze the relationship of various risk factors for pressure ulcers and prediction of ulcer pressure, using Norton and Jackson/Cubbin scale, to incident pressure ulcers in HCU patient. Methods This study utilized a prospective cross-sectional study design to analyze various risk factors for ulcer pressure development in a patient admitted to the HCU, including age, gender, blood profile, consciousness, duration of treatment, and use of restraint. The Norton and Jackson/Cubbin scale was employed to predict pressure ulcers. The relationship between the risk factors and the prediction of pressure ulcer incidents was evaluated using multiple logistic binary regression analysis. Result Both the Norton and Jackson/Cubbin scales predicted a lower risk of pressure ulcer development (60.98 and 99.02%, respectively). This prediction is consistent with the low incidence of pressure injuries found, which is only 4.39%. Furthermore, the relationship between the identified risk factor (gender, duration of treatment in HCU and use of restraint) and the prediction and incident of pressure ulcer was not significant ( p > 0.05). Thus, it is suggested that these risk factors may not strong predictors of pressure ulcer development. Conclusion This study's result indicated no significant relationship exists between possible identified risk factors and the development of pressure ulcers in HCU patients. However, the Norton and Jackson/Cubbin scales were reliable predictors of pressure ulcer occurrence, with both scales predicting a lower risk of pressure ulcer development.

Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes.

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery. A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System. Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition. The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

Wearable Prophylaxis Tool for AI-Driven Identification of Early Warning Patterns of Pressure Ulcers.

As today's society ages, age-related diseases become more frequent. One very common but yet preventable disease is the development of pressure ulcers (PUs). PUs can occur if tissue is exposed to a long-lasting pressure load, e.g., lying on tissue without turning. The cure of PUs requires intensive care, especially for the elderly or people with preexisting conditions whose tissue needs longer healing times. The consequences are heavy suffering for the patient and extreme costs for the health care system. To avoid these consequences, our objective is to develop a pressure ulcer prophylaxis device. For that, we built a new sensor system able to monitor the pressure load and tissue vital signs in immediate local proximity at patient's predilection sites. In the clinical study, we found several indicators showing correlations between tissue perfusion and the risk of PU development, including strongly reduced SpO2 levels in body tissue prior to a diagnosed PU. Finally, we propose a prophylaxis system that allows for the prediction of PU developments in early stages before they become visible. This work is the first step in generating an effective system to warn patients or caregivers about developing PUs and taking appropriate preventative measures. Widespread application could reduce patient suffering and lead to substantial cost savings.

Predictive validity of the Jackson–Cubbin scale for pressure ulcers in intensive care unit patients: A meta‐analysis

AbstractBackgroundThe intensive care unit has a much higher pressure ulcers incidence than general wards. Predicting and eliminating the risk of pressure ulcer development is thus of utmost importance in health care, including clinical nursing practice.AimThe meta‐analysis aimed to examine the predictive validity of the Jackson–Cubbin Scale.MethodsThis study is a systematic literature review and meta‐analysis. Research articles published in periodicals indexed targeted the critical care patients and offered sufficient data(true‐positive, false‐positive, true‐negative and false‐negative results) in the EBSCO, PubMed, Ovid, Web of Science and Cochrane databases, as well as those from two journals indexed in a Chinese database (Wangfang Data and China National Knowledge Infrastructure) were reviewed. Preferred reporting items for systematic reviews and meta‐analyses were used; the internal validity of the diagnostic studies was analysed using Quality Assessment of Diagnostic Accuracy Studies 2. Sensitivity, specificity, positive and negative likelihood ratios were counted by STATA 15.0.ResultsNine diagnostic studies with high methodological quality, involving a total of 7684 patients, were retrieved and assessed. This meta‐analysis showed that the pooled sensitivity, specificity and area under the symmetric summary receiver operating characteristic curve of the Jackson–Cubbin Scale were 0.81 (95% confidence interval [CI], 0.58–0.88), 0.76 (95% CI, 0.51–0.95) and 0.84 (95% CI, 0.81–0.87), respectively.ConclusionsThe study suggests that the Jackson–Cubbin Scale has a moderate level of predictive validity. Moreover, Jackson–Cubbin's predictive validity could be increased if it was implemented differently based on the attributes of the research participants.Relevance to Clinical PracticeThe Jackson–Cubbin Scale has a moderate level of predictive validity with good sensitivity and specificity for the determination of the risk of PUs in adult ICU patients. Bedside nurses could use the Jackson–Cubbin scale for dailly assesment for ICU patients.

High-Intensity Post-Stroke Rehabilitation Is Associated with Lower Risk of Pressure Ulcer Development in Patients with Stroke: Real-World Evidence from a Nationwide, Population-Based Cohort Study.

Background and Objectives: Multiple factors are associated with pressure ulcer (PU) development, including limited mobility following stroke. We performed a nationwide cohort study to investigate the impact of rehabilitation intensity on the incidence of post-stroke PU. Materials and Methods: Data of patients diagnosed with stroke between 2000 and 2012 were collected from the 2000 Longitudinal Health Insurance Database (Taiwan). Based on the number of rehabilitation sessions attended within 90 days of discharge, the rehabilitation intensity was classified as low, medium, or high. After adjusting for sociodemographic factors and comorbidities, the Cox proportional hazards model evaluated the risk of PU development during the 12-year follow-up period. Kaplan–Meier curves were used to estimate the cumulative incidence of PUs. Results: Our study included 18,971 patients who had their first episode of stroke. Of these, 9829 (51.8%) underwent rehabilitation therapy after discharge. Female patients and patients with a National Institutes of Health Stroke Scale (NIHSS) score >13 points, who commenced high-intensity post-stroke rehabilitation after discharge had a significantly lower risk of PU development than those who underwent low-intensity post-stroke rehabilitation after discharge. Cumulative survival analysis showed a significantly lower cumulative incidence of PU during the 12-year follow-up period in the high-intensity rehabilitation group. Conclusion: Compared with low-intensity post-stroke rehabilitation, high-intensity post-stroke rehabilitation after discharge from hospital is associated with a lower risk of post-stroke PU development, especially in female stroke patients and patients with a NIHSS score >13 points. High-intensity rehabilitation is also associated with a significantly lower cumulative incidence of PU events during the 12-year follow-up period.

Pressure ulcer risk profiles of hospitalized patients based on the Braden Scale: A cluster analysis

The aim of this work is to identify the pressure ulcer risk profiles of hospitalized patients with reference to Braden Scale subscales. A total of 2996 hospitalized Portuguese participants were screened using the Braden Scale. A hierarchical and nonhierarchical cluster analysis was conducted, with ethical approval. Five risk profiles (clusters) based on the first risk assessments were identified. Regarding the Braden Scale total score, two profiles with high risk and three profiles with low risk of pressure ulcer development were identified. All clusters were statistically significantly different in terms of sociodemographic and clinical variables. When the first and the last risk assessments were compared, all the clusters improved the Braden Scale total score on the last risk assessment, except Cluster 4 (low-risk category). Clusters 3, 4 and 5, which were classified as low risk, decreased in several Braden subscales at the last risk assessment. The classification of low risk may misguide the early identification of patients with individual risk factors. Increasing the awareness of health care professionals for the importance of risk assessment of each Braden subscale is necessary for pressure ulcer prevention. We recommend the implementation of strategies for early identification of patients at risk at local and national levels.

Handling a patient with suspected COVID-19 infection with a high risk of pressure ulcer development: a case study

Handling a patient with suspected COVID-19 infection with a high risk of pressure ulcer development: a case study

Pressure ulcer prevention-Results of a multicentre cross-sectional survey on hospital infrastructures and processes in acute hospitals and accident and emergency departments.

Pressure ulcers (PUs) are a serious health problem. They can be considered as an indicator of the quality of health care and are associated with considerable cost increases for the health care system. The prevention of PUs is a major concern in hospital care. The aim of the study was to reveal the current PU prevention-related processes and structures with a specific focus on the Accident and Emergency (A&E) Department. In late 2018/early 2019, all German hospitals were invited to participate in a nationwide cross-sectional survey. One standardized questionnaire was assigned to a representative of each hospital. The representative was asked to state what PU-related structures and processes are implemented in their hospital, in general and specific to the A&E department. Besides mostly descriptive analysis, PU-related processes were analysed on PU incidence in a multivariate linear regression model. Two hundred seventy-six hospitals participated in the survey. 63.4% (n=175) of the participating hospitals had at least one PU manager. Skin inspection was the most frequently performed procedure. Although not recommended, 1.3% (2.1%) of the facilities still use sheepskins quite often (very often). In the regression model on PU incidence, only the process 'mobilization in bed' was statistically significantly associated. Although the risk of developing a PU in the emergency department is high, more than half of the facilities had no PU guidelines. Even if recommended procedures (skin inspection, 30° positioning) have been used frequently, regular training could help to bring new scientific findings such as the use of local skin protection dressings into clinical practice. Prevention guidelines should be established in all areas of care even for A&E as well as when patients are transferred inside or out of the hospital, where the risk of PU development was considered low.

Incidence of Pressure Ulcers In The Patients On Mechanical Ventilation: A Prospective Study

Aim: The aim of this study was to determine the incidence of pressure ulcers among the patients on mechanical ventilation.Methods: The type of the study was cross-sectional and prospective. It was carried out in 5 intensive care units of a state hospital located in Western Black Sea region of Turkey. The sample of the study included 260 patients who began to get mechanical ventilatory support. Pressure ulcer risk in patients was assessed by Braden Risk Assessment Scale at 10th hour, 1st week and 2nd week timepoints following the initiation of mechanical ventilatory support. Results: Mean age of the patients was 54±10 years; 52.7% were males; and 55.4% had a Body Mass Index within normal range. It was determined that 46.5% of the patients were hospitalized due to the diagnosis of a cerebrovascular event; the state of consciousness was confused in 52.3% and mean Braden Risk Assessment Scale was 11.0±2.64. It was observed that the incidence of pressure ulcers was 10.8% at 10th hour, 58.5% at first week and 71.15% at second week following the beginning of mechanical ventilation treatment. At the end of second week, stage1 pressure ulcer was developed on the sacrum in 30% and on coccyx area in 22.7% of the patients. Conclusion:It was found that the incidence of pressure ulcer development risk was significantly high among the patients who underwent mechanical ventilation treatment. Considering the effect of mechanical ventilator and other factors, taking primary protective precautions for preventing pressure ulcers was suggested to be very important.

Pressure ulcer Cat. II-IV incidence on the CuroCell S.A.M. PRO powered reactive air support surface in a high-risk population: A multicentre cohort study in 12 Belgian nursing homes.

The primary objective was to study pressure ulcer (PU) category II-IV (including suspected deep tissue injury and unstageable PUs) cumulative incidence and PU incidence density, in a 30day observation period, associated with the use of the CuroCell S.A.M. PRO powered reactive air support surface in nursing home residents at risk for PU development. Secondary objectives were to study (a) PU category I cumulative incidence and PU incidence density and (b) user (caregivers and residents) experiences and perceptions of comfort associated with the use of the support surface under study. A multicentre cohort study was set up in 37 care units of 12 Belgian nursing homes. The sample consisted of 191 residents at risk of PU development (Braden score ≤ 17). The cumulative PU incidence was 4.7% (n = 9). The PU incidence density was 1.7/1000 observation days (9 PU/5370 days). The experience and perceptions of comfort analysis revealed that the CuroCell S.A.M. PRO powered reactive air support surface was comfortable for daily use. The mode of action and the quietness of the pump function had a positive impact on sleep quality. Patient comfort and sleep quality are essential criteria in the selection of a support surface.

A patient-reported pressure ulcer health-related quality of life instrument for use in prevention trials (PU-QOL-P): psychometric evaluation

IntroductionPressure ulcer-specific patient-reported outcome (PRO) instruments should be used to inform patient care and provide a strong evidence base for interventions aimed at preventing pressure ulcers. The aim was to carry out a comprehensive evaluation of the psychometric properties of a PRO instrument designed to assess symptoms and functional outcomes in patients at high-risk of developing pressure ulcers, the PU-QOL-P instrument.MethodsWe modified the original PU-QOL instrument to be suitable for patients at high risk of pressure ulcer development based on feedback from patients, specialist nurses and PRO methodologists. The modified PU-QOL-P instrument was administered to a sub-set of patients participating in the PRESSURE 2 trial. Patients completed PU-QOL-P and SF12 instruments at baseline, weeks 1 and 3, and 30 days post-treatment. We undertook psychometric evaluation of the modified PU-QOL-P to test scale targeting, scaling assumptions, reliability, validity and responsiveness.ResultsThe analysis sample consisted of 617 patients that completed both instruments at baseline. We found that the PU-QOL-P instrument, consisting of nine PU-specific outcomes: three symptom and six function scales, meets established criteria for reliability, construct validity, and responsiveness. Internal consistency reliability was high with all scale Cronbach alpha > 0.795 (range 0.795–0.970). The factor analysis mostly supported the six-function scale structure. Scaling assumptions were satisfied; all item-total correlations above 0.30. Convergent validity was confirmed by significant correlations between hypothesized scales as expected. PU-QOL-P scales were responsive to change: mean scale scores from baseline to 30 days post-treatment were statistically significant for all scales apart the daily activities scale (effect sizes ranged from moderate to high). As expected, worse symptoms and functioning was observed in patients who had a category 1 or 2 PU compared to patients who did not have a PU.ConclusionsThe PU-QOL-P provides a standardised method for assessing pressure ulcer-specific symptoms and functional outcomes for quantifying the benefits of associated interventions from the patient’s perspective. It can be used in research with adults at risk of pressure ulcer development in all UK healthcare settings.

Community care clinicians' experiences and perceptions of Waterlow pressure ulcer risk assessment

Background Pressure ulcer risk assessment tools play a pivotal role in meeting the challenge of the zero pressure ulcer agenda. Clinicians should use their clinical judgement in combination with a validated pressure ulcer assessment tool when detecting and managing patient pressure ulcer development risk. The assessment tool, therefore, should effectively, and reliably direct pressure relieving equipment resources. This is particularly important when considering the influence of the pressure ulcer assessment tool on patterns of care and allocation of resources. Aim To undertake a service evaluation and identify a quality improvement opportunity, surrounding pressure ulcer assessment, prevention, and care practices within one community health services NHS Trust. Method An online questionnaire was purposed-developed to capture the perceptions and experiences of the Trusts clinicians surrounding the assessment, prevention, and management of pressure ulcers using the Waterlow pressure ulcer risk assessment tool. Questionnaire content was developed in collaboration with a panel of Trust employed healthcare and research experts. Data analysis adhered to the principles of an inductively informed six-phase recursive Thematic Analysis. Results Two interrelated themes reflected the clinicians' perceptions and experiences: Confidence in Waterlow Supporting Clinical Decision-Making and Defensively Nursing. Some perceived Waterlow as useful, although flawed tool. Others perceived the use of Waterlow to have negatively influenced working practices by developing 'nursing by numbers' care practices and a propensity for over-prescription of pressure relieving resources. Conclusion The results provide important elucidation surrounding pressure ulcer care practices and provide evidence to support quality improvement innovation within the Trust.

Therapeutic hypothermia and pressure ulcer risk in critically ill intensive care patients: A retrospective study

ObjectiveTo examine the role of therapeutic hypothermia in pressure ulcer development in critically ill patients. Research methodologyRetrospective study in a mixed intensive care unit over 2010–2013. The incidences of pressure ulcers among patients treated with therapeutic hypothermia (n = 148) and the non-hypothermia patient population (n = 6197) were compared. ResultsPatients treated with hypothermia developed more pressure ulcers (25.0%) than the non-hypothermia group 6.3% (p < 0.001). More patients in the hypothermia group were rated as the high pressure ulcer risk group, as defined by the modified Jackson/Cubbin (mJ/C) risk score ≤29 than the rest of the patients. Among the therapeutic hypothermia patients more pressure ulcers tended to emerge in the lower risk group (mJ/C score ≥30) (p = 0.056). Intensive care mortality was higher in the hypothermia (24.3%) than the non-hypothermia group (9.3%, p < 0.0001). ConclusionPatients treated with therapeutic hypothermia should be considered at high risk for pressure ulcer development and should be managed accordingly. The hypothermia may not as such increase the risk for pressure ulcers, but combined with the severity of the underlying illness, may be more likely. The pressure ulcer risk in this patient group cannot be reliably assessed by the Jackson/Cubbin risk scale.

Resultados de la implantación de una Guía de Buenas Prácticas en pacientes con ictus hospitalizados

Stroke is a significant cause of morbidity and mortality in adults and implies high social and health costs. Best Practice Guidelines (BPG) are useful tools for improving patient health outcomes and quality of care. AimTo evaluate the results of BPG implementation in the care of hospitalized stroke patients. MethodPre-post quasi-experimental study. Sample: 18years old or older with a stroke diagnosis admitted to Albacete General Hospital. Duration or Timeline: Baseline measurement (T0; December 2014); Implementation start (T1; October-December 2015); Consolidation (T2; January-December 2016). Variables: Independent; implementation of the guideline “Stroke assessment across the continuum of care”. Results(i)Implementation process: neurological assessment, dysphagia, fall risk, pain detection, pressure ulcer development risk (PUD), health education. (ii)Patient results: Aspiration pneumonia, falls, independence for basic activities of daily life (ADL), PUD, pain. Results457 patients (30 T0, 66 T1, 361 T2). 64.1% men, mean age 68.8years; ischaemic stroke 76.1%, 16.8% transient ischaemic attack (TIA), and 7% haemorrhagic. There were no statistically significant differences in age, sex and independence for ADL between periods, but there were regarding types of stroke diagnoses. There were significant improvements in all process variables per period. The patient results were: 6 pneumonias, 3 PUD and 7 falls; 54.5% patients had ADL independence at discharge. ConclusionsThere were good implementation results of all recommendations, detecting possibilities of improvement in dysphagia assessment and independence assessment at discharge, providing healthcare education and filling of records.

Implementation results of a Best Practice Guideline in stroke patients hospitalized

Stroke is a significant cause of morbidity and mortality in adults and implies high social and health costs. Best Practice Guidelines (BPG) are useful tools for improving patient health outcomes and quality of care. AimTo evaluate the results of BPG implementation in the care of hospitalised stroke patients. MethodPre-post quasi-experimental study. Sample: 18 years old or older with a stroke diagnosis admitted to Albacete General Hospital. Duration or Timeline: Baseline measurement (T0; December 2014); Implementation start (T1; October–December 2015); Consolidation (T2; January–December 2016). Variables: Independent; implementation of the guideline “Stroke assessment across the continuum of care”. Results(i) Implementation process: neurological assessment, dysphagia, fall risk, pain detection, pressure ulcer development risk (PUD), health education. (ii) Patient results: Aspiration pneumonia, falls, independence for basic activities of daily life (ADL), PUD, pain. Results457 patients (30 T0, 66 T1, 361 T2). 64.1% men, mean age 68.8years; ischaemic stroke 76.1%, 16.8% transient ischaemic attack (TIA), and 7% haemorrhagic. There were no statistically significant differences in age, sex and independence for ADL between periods, but there were regarding types of stroke diagnoses. There were significant improvements in all process variables per period. The patient results were: 6 pneumonias, 3 PUD and 7 falls; 54.5% patients had ADL independence at discharge. ConclusionsThere were good implementation results of all recommendations, detecting possibilities of improvement in dysphagia assessment and independence assessment at discharge, providing healthcare education and filling of records.

Relationship between Oxygenation Status and the Risk of Pressure Ulcer Development in Patients after Open Heart Surgery

Relationship between Oxygenation Status and the Risk of Pressure Ulcer Development in Patients after Open Heart Surgery

Possibilities of Evaluation of Psychometric Properties of Scales for Assessment of the Risk of Pressure Lesions at Selected Intensive Care Workplaces – a Pilot Study

Assessment of the inter-rater reliability of scales for the pressure ulcer development risk (Norton, modified Norton, Braden and Jackson/Cubbin modified by Maarit Ahtiala) in patients hospitalized at intensive care units. Material and methods: The pilot stage for the prospective, observational and descriptive study took place in March 2017 at five intensive care units of four different hospitals in the Czech Republic. For each patient, three regular evaluations of pressure ulcer risk were performed by two independent raters at the given workplace using four standardised scales. The pilot study comprised 26 probands of the total number of 173 hospitalized patients, 61.5% (n = 16) men and 38.5% (n = 10) women. Results: For each evaluation of patients, the first raters provided lower score, which is associated with a higher risk of pressure ulcer development. The average scores at rating scales increase from the first evaluation in the course of hospitalization at intensive care units. Conclusion: An important role in the inter-rater reliability and usability of the rating scales consists in the experience with their use and in thorough education of raters. With regard to the total number of probands in the pilot study (n = 26), it is not possible to draw a definite conclusion with the recommendation for a specific scale for rating the pressure ulcers risks in intensive care unit patients. The evaluators in clinical practice found the Jackson/Cubbin scale modified by Maarit Ahtiala as the most practical.

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.

Hemodynamic Status and Its Relationship with the Risk of Pressure Ulcers Development in Patients After Open Heart Surgery

Hemodynamic Status and Its Relationship with the Risk of Pressure Ulcers Development in Patients After Open Heart Surgery