Decreasing the prevalence of pressure ulcers using agency standards

Use of photographs for the identification of pressure ulcers in elderly hospitalized patients: validity and reliability

To evaluate the ability of research nurses to identify pressure ulcers, the authors assembled digital photographs of the skin of 160 consenting elderly patients (80% African American, 63% women). The series included 39 photos of pressure ulcers, 109 of normal skin, and 12 of other skin conditions, determined by consensus by two experts (D.J.M. and S.H.K.). Photos were packaged electronically into eight blocks of 20, with pressure ulcer prevalence ranging from 20% to 30% per block. The eight blocks were duplicated to create two sets of 160 photos each. Each of six raters (experienced clinical research nurses), working independently, evaluated the 320 photos as if each photo depicted a different patient. For analysis, the ratings were collapsed into binary determinations (any pressure ulcer vs. none). The overall sensitivity and specificity of the ratings were 0.97 (95% confidence interval: 0.94, 0.98) and 0.81 (95% confidence interval: 0.77, 0.86), respectively. Rater-specific prevalence (range: 31.8-47.5%) exceeded the true prevalence (24.4%). Inter- and intrarater reliability coefficients were 0.69 and 0.84, respectively. Trained research nurses can accurately classify pressure ulcers from photographs, even when patients are largely non-White and the photographs depict pressure ulcers spanning all pressure ulcer stages.

Pressure ulcers: implementation of evidence-based nursing practice

AIMS

A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper.

BACKGROUND

The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies.

METHOD

The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data.

RESULTS

Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers.

CONCLUSIONS

There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.

Key points on caring for pressure ulcers in home care

Healthcare providers who care for home-based clients who are at risk for or who have a pressure ulcer are confronted with many challenges. Key points specific to caring for home care clients are presented to give specific directions so clinicians can implement pressure ulcer prevention and care for those who have a pressure ulcer.

Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands

The purpose of the present study was to assess the prevalence of pressure ulcers and the use of Dutch guidelines for the prevention and treatment of pressure ulcers. A survey of 16,344 patients in 89 health care institutions on 1 day showed a mean prevalence of pressure ulcers of 23.1%. It was found that Dutch guidelines on some aspects of prevention and treatment of pressure ulcers were not being followed. Only 53% of the patients who should have been positioned on a support surface were positioned on such a device. Fewer than one-third of the patients who should have been repositioned, should have received nutritional support, or should have been educated received these interventions, and only 33.6% of all pressure ulcers were dressed as recommended. More attention to the dissemination and implementation of the guidelines is needed to reduce this high prevalence of pressure ulcers.

How effective are prevention strategies in reducing the prevalence of pressure ulcers?

The prevalence of pressure ulcers has remained constant at about 7% over the past 20 years, even though considerable time and money has been invested in various prevention strategies. This literature review explores whether pressure-prevention programmes can reduce the prevalence rate still lower or whether they are working but are limited by an increasingly aged population and rising patient acuity.