Pressure Ulcer Staging Research Articles

The NPUAP Meeting – This was No Consensus Conference

The National Pressure Ulcer Advisory Panel (NPUAP) held a Consensus Conference on Pressure Ulcer Staging April 8–9, 2016 in Chicago, Illinois. This was conducted by a moderator and six NPUAP members who were designated as the staging task force. This consisted of 4 nurses, 2 of which were nurse practitioners, one dietician and an individual with a Ph.D. in mechanical and aerospace engineering. Their purpose was “to revise the staging definitions to further clarify and refine the system and develop new nomenclature relevant to pressure related soft tissue injury” (Consensus Conference on Pressure Ulcer Staging, 2016). Many of the changes were not made by consensus but were predetermined by the task force. This includes the following changes. Pressure ulcers are now pressure injuries. The stages are described with Arabic numbers rather than Roman numerals. There are two new pressure categories – medical device related pressure injury and mucosal membrane pressure injury. New artwork has been created to depict the stages. There were changes made to all the stages, but only some of this was by consensus. These revisions were announced by press release on April 13, 2016.

Chronic wounds consultation by telemedicine between a rehabilitation healthcare center and nursing home or home

Saint-Hélier Rehabilitation Center (pôle MPR Saint-Hélier), located in Rennes, has been selected for a regional telemedicine project in 2014 about chronic wounds. To make care access easier for heavy disabilities patients in nursing homes or at home with chronic wounds. The members of TLM [email protected] chronic team are specialist doctors and nurses for wounds. On request, the occupational therapist or dietician involve in the consultation (multidisciplinary approach). A secure videoconference (web) is used. Since July 2014, over 100 teleconsultations have been done. Targeted population is constituted by patients: – whose access to care is decreased due to moving difficulties; – of which the health care team is crossing difficulties in the care process (wound care but also disability, nutrition..). Seventy percent of requests come from the nursing home, 30% from homes (pressure ulcers stages 3 and 4, arterial ulcers, venous or mixed). Middle age: 78 years (20–101 years). Only 3 patients refused. Time to organize the teleconsultation is on average 13 days. Consultations last on average 25 minutes. In 30% of cases the teleconsultation is extended by a real live training time for the nurse at home guided by the TLM [email protected] chroniques team. We evaluate professional satisfaction and technical satisfaction. Without teleconsultation, in 77% of cases transportation request for consultation would be made, in 5% hospitalization. In 18% no request would be done. These first results, encouraging, confirms the interest of specialized consultations in medico-social settings, and telemedicine can be an effective solution.

Clinical Nurse Specialist Collaboration to Recognize, Prevent, and Treat Pediatric Pressure Ulcers.

The purpose of this quality improvement project was to reduce the incidence of pressure ulcers in a 232-bed, freestanding children's hospital in Western United States. Pressure ulcers have been an underappreciated hospital-acquired condition in children. Children have distinct anatomic, physiologic, and developmental factors that alter how pressure ulcers occur, but nurses may not recognize the pediatric patient as at risk because of lack of knowledge and tools to assess skin, identify risk factors, and recognize or stage pressure ulcers. Our initial efforts to develop organizational tools to reduce pediatric pressure ulcers were not sufficient, despite improvements in care. Interprofessional and intraprofessional collaboration, led by clinical nurse specialists, focused on documentation, tracheostomies, respiratory devices, and hemodynamically unstable or extracorporeal life support patients. Stage 3 and 4 and unstageable pressure ulcers are also "never events" in children. The unique factors involved with infant and pediatric pressure ulcers demand unique solutions. Our collaborative efforts led to a significant and sustained reduction in pressure ulcer incidence, from 3.3 per 1000 patient days in the first quarter of 2010 to 1.7 per 1000 patient days in the second quarter of 2014. Reportable pressure ulcers were reduced by 60%. Improved awareness and prevention strategies also led to significant reductions in extracorporeal life support patient pressure ulcers and respiratory device-related pressure ulcers. Through intraprofessional and interprofessional collaboration, the clinical nurse specialists were able to implement sustained organizational change and improve care for infants and children. Reduction in pressure ulcers is achievable but requires collaboration and creative solutions that involve multiple disciplines.

Under Pressure: Financial Effect of the Hospital-Acquired Conditions Initiative-A Statewide Analysis of Pressure Ulcer Development and Payment.

To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals. Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed. Nonfederal acute care California hospitals (N = 311). Adults discharged from acute-care hospitals. Pressure ulcer rates and hospital payment changes. Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare. The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the Hospital-Acquired Conditions Initiative.

A review of nursing care of pressure ulcer at different stage

Pressure ulcer care were always the focus and difficulty of nursing work. Timely and effective care were helpful to promote the repair of pressure ulcer. This article described and compared the different stages of system pressure sores assessment. This article mainly summarized the effective nursing methods at every stage of pressure ulcer at present, which were helpful to carry out evidence-based care and improve the quality of nursing. Key words: Pressure ulcer; Nursing care; Review

Pelvic pressure ulcer reconstructions by pedicled muscle flaps

Introduction: Pelvic region is the most predisposed topographic area of the body to pressure ulcers in immobile patients. This communication presents the experience of the authors and set to discussion the value of the pedicled muscle flaps in the management of pressure ulcers stage III and IV. Material and Methods: The study was conducted during the period from May 2006 to December 2014. A total of 11 muscle based flaps were applied on 5 male and one female patients with deep pressure ulcers in the pelvic region. Musculus gluteus maximus (MGM), musculus gracilis (MG), musculus hamstring (MH), musculus vastus lateralis femoris (MVLF) and musculus rectus abdominis (MRA) were designed as monocomponent muscle or compound skin-muscle flaps in accordance with the wound characteristics. Results: The patients were followed-up from 1 month to 6 years. All flaps were vital. Small area partial skin necrosis of the MRA flap and MH advancement flap required secondary surgical procedures within a month after the reconstruction. Four recurrences through variable periods were observed in one patient, operated on by different muscle flaps. Conclusion: Pressure ulcers are a frequent complication in immobile patients. Surgery is the most effective treatment method for wounds at stages III and IV. Patient’s general condition and wound status should be taken into consideration when planning the reconstruction. The vitality and volume of the muscle flaps are the main advantages of that alternative for surgical treatment of pelvic pressure sores.

Comparative Effectiveness of Quality Improvement Interventions for Pressure Ulcer Prevention in Academic Medical Centers in the United States

Prevention of pressure ulcers, one of the hospital-acquired conditions (HACs) targeted by the 2008 nonpayment policy of the Centers for Medicare & Medicaid Services (CMS), is a critical issue. This study was conducted to determine the comparative effectiveness of quality improvement (QI) interventions associated with reduced hospital-acquired pressure ulcer (HAPU) rates. In an quasi-experimental design, interrupted time series analyses were conducted to determine the correlation between HAPU incidence rates and adoption of QI interventions. Among University HealthSystem Consortium hospitals, 55 academic medical centers were surveyed from September 2007 through February 2012 for adoption patterns of QI interventions for pressure ulcer prevention, and hospital-level data for 5,208 pressure ulcer cases were analyzed. Between- and within-hospital reduction significance was tested with t-tests post-CMS policy intervention. Fifty-three (96%) of the 55 hospitals used QI interventions for pressure ulcer prevention. The effect size analysis identified five effective interventions that each reduced pressure ulcer rates by greater than 1 case per 1,000 patient discharges per quarter: leadership initiatives, visual tools, pressure ulcer staging, skin care, and patient nutrition. The greatest reductions in rates occurred earlier in the adoption process (p<.05). Five QI interventions had clinically meaningful associations with reduced stage III and IV HAPU incidence rates in 55 academic medical centers. These QI interventions can be used in support of an evidence-based prevention protocol for pressure ulcers. Hospitals can not only use these findings from this study as part of a QI bundle for preventing HAPUs.

Bodily pain intensity in nursing home residents with pressure ulcers: analysis of national minimum data set 3.0.

Clinical reports suggest that superficial pressure ulcers produce pain, but that pain decreases as the wound advances in stage. This study of the relationship between pressure ulcer stage and bodily pain intensity in nursing home residents was a secondary analysis of the national Minimum Data Set 3.0 assessment data in long-term care facilities, collected from nursing home residents at least 65 years of age. Data were examined from residents with pressure ulcers who completed a bodily pain intensity interview between January and March 2012 (N = 41,680) as part of the MDS comprehensive assessment. After adjusting for other variables (e.g., cognition, functional impairment, presence of comorbidities, use of scheduled pain medication, and sociodemographic variables), bodily pain intensity for those with more severe pressure ulcers in comparison to those with Stage I ulcers was higher by 11% (Stage II), 14% (Stage III), 24% (Stage IV), and 22% (suspected deep tissue injury). Because multivariate analysis showed that greater bodily pain intensity was associated with an advanced stage of pressure ulcer, health care providers should assess bodily pain intensity and order appropriate pain management for nursing home residents with pressure ulcers, particularly for those with advanced pressure ulcers who are vulnerable to greater bodily pain intensity.

Incidence and risk factors for surgically acquired pressure ulcers: a prospective cohort study investigators.

To assess the incidence of hospital-acquired, surgery-related pressure injury (ulcers) and identify risk factors for these injuries. We used a prospective cohort study to investigate the research question. The study was conducted at a major metropolitan hospital in Brisbane, Australia. Five hundred thirty-four adult patients booked for any surgical procedure expected to last more than 30 minutes were eligible for inclusion. Patients who provided informed consent for study participation were assessed for pressure ulcers, using the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Guidelines, before entering the operating room and again in the post-anesthetic care unit (PACU). Research nurses and all PACU nurses were trained in skin assessment and in pressure ulcer staging. Patients were not assessed again after their discharge from the PACU. Seven patients (1.3%) had existing pressure injuries (ulcers) and a further 6 (1.3%) developed a surgery-related pressure ulcer. Risk factors associated with surgery-related pressure injuries were similar to non-surgically related risks and included older age, skin condition, and being admitted from a location other than one's own home. Length of surgery was not associated with pressure ulcer development in this cohort. Perioperative nurses play an important role in identifying existing or new pressure injuries. However, many of these nurses are unfamiliar with pressure ulcer classification, so education in this area is essential. Although the incidence of surgically acquired pressure ulcers was low in this cohort, careful skin inspection before and after surgery provides an opportunity for early treatment and may prevent existing lesions progressing to higher stages.

Factors associated with pressure ulcer risk in spinal cord injury rehabilitation.

The aim of this study was to identify patient and clinical factors most strongly associated with a spinal cord injury patient's risk for developing a pressure ulcer (PU) during rehabilitation. This is a prospective observational cohort study conducted at an urban rehabilitation hospital-based specialized spinal cord injury center. The main outcome measure was the onset of a stage 2 or higher PU. Study patients (N = 159) with new (n = 66) and patients with earlier (n = 99) spinal injuries had identical rates at which they acquired a new PU (stage ≥2) in rehabilitation--13.1%. The patients who came to rehabilitation with a PU or myocutaneous flap exhibited a higher rate of developing yet another PU while in rehabilitation (30.2%) than those who came to rehabilitation without an existing PU or flap (6.9%). Logistic regression analysis identified two variables that best predicted a patient's risk at admission for developing a PU during rehabilitation (c = 0.77)--entering rehabilitation with a PU and admission Functional Independence Measure transfers score of less than 3.5. The greatest risk of developing a new PU in rehabilitation is being admitted with an existing PU followed by admission Functional Independence Measure transfers score of less than 3.5. Using these two variables, one can develop a patient PU risk algorithm at admission that can alert clinicians for the need to enhance vigilance, skin monitoring, and early patient education.

The Effect of Application Parameter of Pulsed Direct Current on Wound Healing of Patients with Pressure Ulcer

This study investigated the effects of changes to the pulsation factor of pulsed direct currents on wound healing. Patients with a pressure ulcer at a care hospital for the elderly were randomly divided into three groups: Group 1 involved the application of in pulse duration, 10 ms in pulse period, 100 pps in a pulsation factor, 15 mA in pulse amplitude, and polarity red+ by using pulsed direct currents; Group 2 involved a change of pulse period to 8 ms; and Group 3 received general wound management. Although there were no statistically significant differences in the changing stages of pressure ulcers among the groups, all the groups dropped in numerical stages. In the two groups to which pulsed direct currents were applied, there was a statistically significant reduction in the stages of pressure ulcers from the initial assessment to the 12-week assessment (p

Teaching the fruits of pressure ulcer staging.

Accurate pressure ulcer staging is an important skill for nurses, physicians, physical therapists, and certified nursing assistants. Current education is based on the National Pressure Ulcer Advisory Panel's staging system. A review of the literature indicates variability in staging abilities of numerous healthcare providers. With this problem in mind, a new method of teaching pressure ulcer staging by visual analogy was developed. We used the current National Pressure Ulcer Advisory Panel definitions to create a training tool based on a visual analogy between the different pressure ulcer stages and common fruits and vegetables. Initial feedback from a western states wound care conference indicates successful integration of teaching into nursing practice. A poster was also presented at the annual 2011 Wound, Ostomy and Continence Nurse's National Conference. Positive feedback was received from numerous Wound, Ostomy and Continence Nurse's members who requested an electronic copy of the poster. Visual analogies can provide a method of teaching pressure ulcer staging across different disciplines with different levels of training involved in patient care.

Informatics: International Classification of Diseases-10: Implications for Nursing

One of the biggest events to hit healthcare data in decades is the conversion of coded clinical data to the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision, commonly referred to as ICD-10. The last change of this nature was in 1983 when Medicare implemented ICD-9 as part of the Inpatient Prospective Payment System (IPPS). Since that time, healthcare has advanced significantly and ICD-9 codes no longer represent the advances and complexities in care provided to patients; thus healthcare in the United States is expected to transition to ICD-10 on October 1, 2015.ICD-10 is intended to support the systematic recording, analysis, interpretation, and comparison of morbidity and mortality data from around the world (World Health Organization, 2011). There are two parts to ICD-10: ICD-10Clinical Modification (CM) and ICD-10- Procedure Coding System (PCS). Compared to ICD-9-CM with 14,000 codes, ICD-10-CM has 69,000 available codes to be used for diagnosis codes on all inpatient and outpatient accounts. In ICD-9-PCS there are approximately 3,000 codes; this will change with ICD-10-PCS to 72,000 available codes to be used only for inpatient procedural coding.ICD-10 will touch everything from registration and scheduling, to revenue cycle and payer contracts, information systems, and ultimately will be used to improve patient care and outcomes. The important and widespread uses of ICD-10 data make it critical to understand these new documentation requirements. As healthcare prepares for ICD-10 and the coding of data using an electronic platform, it is important to ask, What are the implications for nursing? Although the answer to this question is not easily found, this informatics column will shed light on the issue by providing a sample case and highlighting the role of nurse informaticists in this historical change in healthcare data. We will conclude that nursing's role in data collection and entry is important in the building of the ICD-10 database, and that the benefits to be achieved from this monumental effort are dependent on accurate documentation and coding.Sample Case: Pressure UlcerPressure ulcer was chosen as a sample case to examine in this column due to the costs incurred in treating pressure ulcers. It was also chosen based on the historical precedent whereby staging of pressure ulcers has been coded in ICD-9-CM from nursing charting/documentation (.Cfin.ters..fQr-MlfidLcare-&jyiadicai,d..S.er.v:ic.es.l[CMS3-& .N,ati.Q.n.aL.Cen.ter for Health ..Statistics LN.CHS.].,. 2.Q.Q.S).MethodThe following steps were used to identify nursing documentation needs for pressure ulcers related to ICD-10.1. Define pressure ulcers.2. Download the ICD-10-CM codes and identify all diagnoses related to pressure ulcers.3. Identify the data elements, i.e., the words used, in the pressure ulcer diagnoses in ICD-10-CM codes.4. Identify related data elements in the current electronic health record (EHR) nursing documentation on pressure ulcers.5. Perform a gap analysis between current EHR documentation by nurses on pressure ulcers and what is needed for nursing documentation in ICD-10-CM.6. Reconcile findings with other databases using nursing documentation on pressure ulcers in short-stay hospitals.7. Collaborate with health information management (HIM) to validate findings.8. Present findings to Chief Nursing Officers, as well as wound care nurses and physical therapists.9. Work with information technology EHR builders to build the data base related to ICD-10-CM that is needed for nurses to document in the EHR.10. Prepare educational materials for staff nurses regarding the changes in pressure ulcer documentation for ICD-10-CM.11. Pilot education materials among staff nurses, making adjustments as needed.12. Disseminate educational materials/offerings regarding nursing documentation of pressure ulcers related to ICD-10-CM. …

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

ObjectiveTo determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.DesignSurvey.SettingTertiary spinal cord rehabilitation center and skilled nursing facilities.ParticipantsTwenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.Outcome measuresTotal protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.ResultsWound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.ConclusionsThe biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.

A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention.

To enhance the learner's competence with knowledge about a framework of quality improvement (QI) interventions to implement evidence-based practices for pressure ulcer (PrU) prevention. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Summarize the process of creating and initiating the best-practice framework of QI for PrU prevention.2. Identify the domains and QI interventions for the best-practice framework of QI for PrU prevention. Pressure ulcer (PrU) prevention is a priority issue in US hospitals. The National Pressure Ulcer Advisory Panel endorses an evidence-based practice (EBP) protocol to help prevent PrUs. Effective implementation of EBPs requires systematic change of existing care units. Quality improvement interventions offer a mechanism of change to existing structures in order to effectively implement EBPs for PrU prevention. The best-practice framework developed by Nelson et al is a useful model of quality improvement interventions that targets process improvement in 4 domains: leadership, staff, information and information technology, and performance and improvement. At 2 academic medical centers, the best-practice framework was shown to physicians, nurses, and health services researchers. Their insight was used to modify the best-practice framework as a reference tool for quality improvement interventions in PrU prevention. The revised framework includes 25 elements across 4 domains. Many of these elements support EBPs for PrU prevention, such as updates in PrU staging and risk assessment. The best-practice framework offers a reference point to initiating a bundle of quality improvement interventions in support of EBPs. Hospitals and clinicians tasked with quality improvement efforts can use this framework to problem-solve PrU prevention and other critical issues.

An image mining based approach to detect pressure ulcer stage

Treatment of pressure ulcers (PU) is essentially image dependent, because its surface provides relevant visual information for medical procedures. There is an increasing interest to adapt Information Technology advances for a more effective medical image processing. Artificial Intelligence concerned techniques, say Image Mining, can be very helpful to manage large amount of PU images in order to increase productivity of health professionals and patients life quality. This paper proposes an Image Mining based system for automatic interpretation of tissue and color to support the treatment of patients with PU.

Oral Treatment of Pressure Ulcers with Polaprezinc (Zinc L-carnosine Complex): 8-Week Open-Label Trial

Polaprezinc (zinc L-carnosine complex) is a tablet commonly prescribed for gastric ulcers in Japan. Recently, we reported the effects of polaprezinc on pressure ulcer healing at 4-week follow-up. We aimed to further evaluate the efficacy and safety of polaprezinc in 8-week treatment for chronic pressure ulcers. Patients with stage II-IV pressure ulcers for ≥ 8 weeks received 150 mg/day polaprezinc (containing 116 mg L-carnosine and 34 mg zinc) per os for a maximum of 8 weeks. We measured the severity of pressure ulcers weekly using the Pressure Ulcer Scale for Healing (PUSH) score and monitored blood biochemistry. Fourteen patients (nine men; 68.4 ± 11.8 years) were enrolled. Pressure ulcer stages were II (one patient; 7 %), III (nine; 64 %), and IV (four; 29 %). The PUSH score improved significantly from 8.1 [95 % CI, 6.0-10.3] at baseline to -1.4 [-4.0 to 1.1] after 8 weeks (P < 0.001). Differences from baseline were significant after 1 week (P < 0.05). The mean weekly improvement in PUSH score was 2.0. Eleven patients healed within 8 weeks and none dropped out. Serum zinc levels increased significantly (P < 0.001), whereas serum copper levels (P = 0.001) and copper/zinc ratios (P < 0.001) decreased significantly. In one patient, preexisting copper deficiency deteriorated. These preliminary data suggest that polaprezinc may be effective and well-tolerated in 8-week treatment of pressure ulcers and could be a candidate for their oral treatment.

Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care

BackgroundThe study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, CanadaMethodsWe conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost.Results12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to ‘usual care’. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing.ConclusionEnhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs.Trial registrationClinicalTrials.gov identifier NCT01232764

Peer-to-peer learning/teaching: An effective strategy for changing practice and preventing pressure ulcers in the surgical patient

Hospitals are increasingly focused on finding cost effective ways to ensure patient safety and enhance quality outcomes. Hospitalized patients are at increased risk for a variety of complications, one of the most common is the development of pressure ulcers. In 2008, the Center for Medicare and Medicaid services, the largest payer source for older adults in the US, began to withhold reimbursement to care facilities for pressure ulcers (Stage 3 or 4) that develop as a result of hospitalization. Staff nurses are ideally positioned to prevent the development of hospital acquired pressure ulcers (HAPUs); however, studies reveal several barriers including a knowledge deficit of causative factors, incorrect identification and staging of wounds, inaccurate use of risk assessment tools and an under utilization of evidence-supported prevention intervention strategies (Ilesanmi et al., 2012; Sievers et al., 2012). This paper examines a cost effective, innovate approach to address these barriers and reduce hospital acquired pressure ulcers using peer-to-peer learning/teaching with staff nurses.

Pressure Ulcer Stages among Bed-Ridden Patients in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria- Nigeria

This study was carried out to assesspressure ulcer stages among bed-ridden patients in Medical, Neurosurgical and Orthopaedic wards inAhmadu Bello University Teaching Hospital (ABUTH) Shika-Zaria. The main aim of this study is to determine the prevalence as well as the stages of pressure ulcers among bed-ridden patients and to assess the Nurses’ awareness and application of the awareness in the stage-based treatment of pressure ulcer in ABUTH. The descriptive survey design was adopted and data was collected with the help of questionnaire and observation checklist. A convenient sampling method was used among the bed-ridden patients and a single-stage cluster method was used among the nurses in the three wards. The study sample consisted of 51 Nurses whom answered a pre-established Questionnaire and 129 bed-ridden patients whom were observed using Observational Checklist. The Major Findings were as follows: the cumulative point prevalence of Pressure ulcer was noted to be 18.6% which is significantly high; Pressure ulcer stages were observed to be highest for Stages III (37.5%), and Stage IV (33.3%) which are the advanced stages, and then low in Stage II (20.8%) and Stage I (8.3%). Furthermore, 96% of Nurses were observed to be aware of pressure ulcer stages and 82% apply their awareness in the stage-based treatment of pressure ulcer. In conclusion, there was a high prevalence of pressure ulcer among bed-ridden patients majority of which were the advanced stage of the condition. Therefore it is recommended that, use of a risk assessment tool such as theBraden Scale on admission will identify if the client has pressure ulcer or not, and if they do, at which stage, health care professionals should be more informed about secondary conditions that may occur in the course of patient’s stay in the hospital rather than emphasis only on primary condition that warranted admission, and patient’s relatives should be informed about the risk factors for the development of pressure ulcers since they are also fully involved in the care.