A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes

Investigation of factors associated with pressure ulcer in patients receiving home care services via path analysis

BACKGROUND

Recent trends indicate a rise in the number of elderly and bedridden patients enrolled in home care programs, leading to an increased occurrence of complications such as pressure ulcers within the home health care setting.

OBJECTIVE

The primary objective of this research was to ascertain the prevalence of pressure ulcers and identify the associated factors in adults who were recipients of home health care services.

METHOD

This study, adopting a cross-sectional design, encompassed a sample of 566 patients who sought services from the Home Health Care Unit in a specific province in Turkey. The timeframe for data collection spanned from August to November 2022, during which two primary instruments were employed: the "Demographic Characteristics Form" and two specific scales - the "Braden Pressure Ulcer Risk Assessment Scale" and the "ITAKI Falls Risk Scale."

FINDINGS

In this study, the average age of patients receiving home health care services was identified as 75.9 years, with a standard deviation of 15.1 years. Furthermore, 73.7 % of these patients were classified as being at risk for developing pressure ulcers. The study identified a direct correlation between the risk of BRADEN pressure ulcers and the escalation in scores across several parameters. These parameters included "Addiction Status," delineated as a spectrum from addicted to non-addicted, the "Number of Medical Diagnoses," quantified on a scale, the "State of Consciousness," categorized from clear to confused, and the scores derived from the "ITAKI" scale.

CONCLUSION

The findings of this study highlight the significance of pressure ulcers as a critical health issue among patients receiving home care services. It underscores the necessity for home care nurses to be acutely aware of the risk factors associated with pressure ulcers among high-risk patients.

Negative pressure wound therapy for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, pressure sores, or pressure injuries, are localised damage to the skin and underlying soft tissue, usually caused by intense or long-term pressure, shear, or friction. Negative pressure wound therapy (NPWT) has been widely used in the treatment of pressure ulcers, but its effect needs to be further clarified. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To evaluate the effectiveness of NPWT for treating adult with pressure ulcers in any care setting.

SEARCH METHODS

On 13 January 2022, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase, and EBSCO CINAHL Plus. We also searched ClinicalTrials.gov and the WHO ICTRP Search Portal for ongoing and unpublished studies and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of adults with pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection, data extraction, risk of bias assessment using the Cochrane risk of bias tool, and the certainty of the evidence assessment using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. Any disagreement was resolved by discussion with a third review author.

MAIN RESULTS

This review included eight RCTs with a total of 327 randomised participants. Six of the eight included studies were deemed to be at a high risk of bias in one or more risk of bias domains, and evidence for all outcomes of interest was deemed to be of very low certainty. Most studies had small sample sizes (range: 12 to 96, median: 37 participants). Five studies compared NPWT with dressings, but only one study reported usable primary outcome data (complete wound healing and adverse events). This study had only 12 participants and there were very few events; only one participant was healed in the study (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.15 to 61.74, very low-certainly evidence). There was no evidence of a difference in the number of participants with adverse events in the NPWT group and the dressing group, but the evidence for this outcome was also assessed as very low certainty (RR 1.25, 95% CI 0.64 to 2.44, very low-certainty evidence). Changes in ulcer size, pressure ulcer severity, cost, and pressure ulcer scale for healing (PUSH) sores were also reported, but we were unable to draw conclusions due to the low certainly of the evidence. One study compared NPWT with a series of gel treatments, but this study provided no usable data. Another study compared NPWT with 'moist wound healing',  which did not report primary outcome data. Changes in ulcer size and cost were reported in this study, but we assessed the evidence as being of very low certainty; One study compared NPWT combined with internet-plus home care with standard care, but no primary outcome data were reported. Changes in ulcer size, pain, and dressing change times were reported, but we also assessed the evidence as being of very low certainty. None of the included studies reported time to complete healing, health-related quality of life, wound infection, or wound recurrence.

AUTHORS' CONCLUSIONS

The efficacy, safety, and acceptability of NPWT in treating pressure ulcers compared to usual care are uncertain due to the lack of key data on complete wound healing, adverse events, time to complete healing, and cost-effectiveness.  Compared with usual care, using NPWT may speed up the reduction of pressure ulcer size and severity of pressure ulcer, reduce pain, and dressing change times. Still, trials were small, poorly described, had short follow-up times, and with a high risk of bias; any conclusions drawn from the current evidence should be interpreted with considerable caution. In the future, high-quality research with large sample sizes and low risk of bias is still needed to further verify the efficacy, safety, and cost-effectiveness of NPWT in the treatment of pressure ulcers. Future researchers need to recognise the importance of complete and accurate reporting of clinically important outcomes such as the complete healing rate, healing time, and adverse events.

Unhealed Pressure Ulcers Among Nursing Home Residents with Diabetes

INTRODUCTION

Nearly a third of US nursing home residents have diabetes mellitus. These residents have an increased risk of pressure ulcer (PU) development and progression; however, little is known about the characteristics of their PUs or the role of other risk factors. This study estimates the prevalence of PUs, describes characteristics of PUs, and quantifies associations between risk factors and PUs in nursing home residents with diabetes.

METHODS

We conducted a cross-sectional study of nursing home residents aged ≥50 years with diabetes mellitus using national 2016 Minimum Data Set 3.0 data. Pressure ulcers were defined as the presence of any stage PU and by subgroups of stage and tissue type. Prevalence estimates of PUs were calculated overall and by covariate subgroups. Unadjusted and adjusted odds ratios were calculated using logistic regression.

RESULTS

The prevalence of any unhealed PU was 8.1%. Of those with a PU, 19.4% had at least two ulcers and the most common subtypes were identified as unstageable and stage 2 ulcers. These were most often treated by pressure reducing devices. In our fully adjusted model, risk factors that were strongly associated with PUs were related to mobility, nutrition, incontinence, and infections.

CONCLUSION

We observed that the prevalence of PUs remains high in nursing home residents with diabetes and that higher stage ulcers were common in this population. Our adjusted model highlights the importance of suspected risk factors in the development of PUs. Further research is needed to understand the unique needs of nursing home residents with diabetes.

Reconstructive surgery for treating pressure ulcers

BACKGROUND

There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as repositioning, to reconstructive surgery. The surgical approach is usually reserved for recalcitrant wounds (where the healing process has stalled, or the wound is not responding to treatment) or wounds with full-thickness skin loss and exposure of deeper structures such as muscle fascia or bone. Reconstructive surgery commonly involves wound debridement followed by filling the wound with new tissue. Whilst this is an accepted means of ulcer management, the benefits and harms of different surgical approaches, compared with each other or with non-surgical treatments, are unclear. This is an update of a Cochrane Review published in 2016.

OBJECTIVES

To assess the effects of different types of reconstructive surgery for treating pressure ulcers (category/stage II or above), compared with no surgery or alternative reconstructive surgical approaches, in any care setting.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was January 2022.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that assessed reconstructive surgery in the treatment of pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, extracted study data, assessed the risk of bias and undertook GRADE assessments. We would have involved a third review author in case of disagreement.

MAIN RESULTS

We identified one RCT conducted in a hospital setting in the USA. It enrolled 20 participants aged between 20 and 70 years with stage IV ischial or sacral pressure ulcers (involving full-thickness skin and tissue loss). The study compared two reconstructive techniques for stage IV pressure ulcers: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialised and deeply inset to obliterate dead space. There were no clear data for any of our outcomes, although we extracted some information on complete wound healing, wound dehiscence, pressure ulcer recurrence and wound infection. We graded the evidence for these outcomes as very low-certainty. The study provided no data for any other outcomes.

AUTHORS' CONCLUSIONS

Currently there is very little randomised evidence on the role of reconstructive surgery in pressure ulcer management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.

Proteomics Identification of Targets for Intervention in Pressure Ulcers

Pressure ulcers (PUs) are chronic wounds that lead to amputations and death. Little is known about why PUs are recalcitrant to healing. Wound healing is mediated by matrix metalloproteinases (MMPs). The 24 MMPs in humans each exist in three forms, of which only one is catalytically competent. We analyzed human PU samples using an affinity resin that exclusively binds to the catalytically competent MMPs. We identified by mass spectrometry the active forms of MMP-1, MMP-8, MMP-9, and MMP-14. Concentrations of MMP-8, MMP-9, and MMP-14 were higher in human PUs compared to the healthy tissue, whereas those for MMP-1 did not change. Decreasing levels of active MMP-9 as the PU improved argued for a detrimental role for this enzyme. In a mouse model of PUs, a highly selective inhibitor for MMP-9 and MMP-14, (R)-ND-336, accelerated wound closure in parallel with significant amelioration of ulcer stage. (R)-ND-336 holds promise as a first-in-class treatment for PUs.

Risk Factors for Pressure Injuries in Adult Patients: A Narrative Synthesis

Pressure injuries remain a serious health complication for patients and nursing staff. Evidence from the past decade has not been analysed through narrative synthesis yet. PubMed, Embase, CINAHL Complete, Web of Science, Cochrane Library, and other reviews/sources were screened. Risk of bias was evaluated using a slightly modified QUIPS tool. Risk factor domains were used to assign (non)statistically independent risk factors. Hence, 67 studies with 679,660 patients were included. In low to moderate risk of bias studies, non-blanchable erythema reliably predicted pressure injury stage 2. Factors influencing mechanical boundary conditions, e.g., higher interface pressure or BMI < 18.5, as well as factors affecting interindividual susceptibility (male sex, older age, anemia, hypoalbuminemia, diabetes, hypotension, low physical activity, existing pressure injuries) and treatment-related aspects, such as length of stay in intensive care units, were identified as possible risk factors for pressure injury development. Health care professionals' evidence-based knowledge of above-mentioned risk factors is vital to ensure optimal prevention and/or treatment. Openly accessible risk factors, e.g., sex, age, BMI, pre-existing diabetes, and non-blanchable erythema, can serve as yellow flags for pressure injury development. Close communication concerning further risk factors, e.g., anemia, hypoalbuminemia, or low physical activity, may optimize prevention and/or treatment. Further high-quality evidence is warranted.

The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations

GENERAL PURPOSE

To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendations.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Distinguish nutrition and malnutrition, especially as they relate to the development and healing of pressure injuries.2. Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations.3. Identify interventions for improving nutrition status and promoting pressure injury healing.

ABSTRACT

Macro- and micronutrients are required by each organ system in specific amounts to promote the growth, development, maintenance, and repair of body tissues. Specifically, nutrition plays an important role in the prevention and treatment of pressure injuries. The purpose of this manuscript is to review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Nutrition for pressure injury management is discussed in the context of the recommendations.

The cutaneous microbiome in hospitalized patients with pressure ulcers

This study investigated whether there are differences in the composition of the cutaneous microbiome of the unaffected skin between patients with pressure ulcers compared with those without pressure ulcers. The cutaneous microbiome of the unaffected skin of 15 patients with sacral pressure ulcers compared to 15 patients without pressure ulcers was analysed. It demonstrated that the inter-individual variation in skin microbiota of patients with pressure ulcers was significantly higher (P = 0.01). The abundance of 23 species was significantly different with Staphylococcus aureus and unclassified Enterococcus the most abundant species in patients with pressure ulcers. Random Forest models showed that eight species were associated with pressure ulcers occurrence in 81% of the patients. A subset of four species gave the strongest interaction. The presence of unclassified Enterococcus had the highest association with pressure ulcer occurrence. This study is the first to demonstrate that the cutaneous microbiome is altered in patients with pressure ulcers.

The Virtual-Spine Platform-Acquiring, visualizing, and analyzing individual sitting behavior

Back pain is a serious medical problem especially for those people sitting over long periods during their daily work. Here we present a system to help users monitoring and examining their sitting behavior. The Virtual-Spine Platform (VSP) is an integrated system consisting of a real-time body position monitoring module and a data visualization module to provide individualized, immediate, and accurate sitting behavior support. It provides a comprehensive spine movement analysis as well as accumulated data visualization to demonstrate behavior patterns within a certain period. The two modules are discussed in detail focusing on the design of the VSP system with adequate capacity for continuous monitoring and a web-based interactive data analysis method to visualize and compare the sitting behavior of different persons. The data was collected in an experiment with a small group of subjects. Using this method, the behavior of five subjects was evaluated over a working day, enabling inferences and suggestions for sitting improvements. The results from the accumulated data module were used to elucidate the basic function of body position recognition of the VSP. Finally, an expert user study was conducted to evaluate VSP and support future developments.

A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial

OBJECTIVES

Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.

DESIGN

This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM.

SETTINGS

Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia.

PARTICIPANTS

A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%.

INTERVENTION

Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL.

MEASUREMENTS

Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers.

RESULTS

Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations.

CONCLUSION

Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.

Assessment of Risk Factors Associated With Hospital-Acquired Pressure Injuries and Impact on Health Care Utilization and Cost Outcomes in US Hospitals

Hospital-acquired pressure injuries (HAPI) are a societal burden and considered potentially preventable. Data on risk factors and HAPI burden are important for effective prevention initiatives. This study of the 2009-2014 US Premier Healthcare Database identified HAPI risk factors and compared outcomes after matching HAPI to non-HAPI patients. The cumulative incidence of HAPI was 0.28% (47 365 HAPI among 16 967 687 total adult inpatients). Among the matched sample of 110 808 patients (27 702 HAPI), the strongest risk factors for HAPI were prior PI (odds ratio [OR] = 12.52, 95% confidence interval [CI] = 11.93-13.15), prior diabetic foot ulcer (OR = 3.43, 95% CI = 3.20-3.68), and malnutrition (OR = 3.11, 95% CI = 3.02-3.20). HAPI patients had longer adjusted length of stay (3.7 days, P < .0001), higher total hospitalization cost ($8014, P < .0001), and greater odds of readmissions through 180 days (OR = 1.60, 95% CI = 1.55-1.65). This study demonstrates how big data may help quantify HAPI burden and improve internal hospital processes by identifying high-risk patients and informing best practices for prevention.

Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study

STUDY DESIGN

Secondary analysis of data from a prospective cohort study.

OBJECTIVES

The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury.

SETTING

The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States.

METHODS

Adults with acute traumatic spinal cord injury (n=104) were recruited within 24-72 h of admission to the hospital. Pressure ulcer incidence was recorded.

RESULTS

Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1-20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3-16.63), P=0.01.

CONCLUSION

Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

Dressings and topical agents for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality.

SEARCH METHODS

In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision.

AUTHORS' CONCLUSIONS

A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.

Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

OBJECTIVE

To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development.

DESIGN

Multicentre prospective cohort study.

SETTING

UK hospital and community settings.

PARTICIPANTS INCLUSION

Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU).

EXCLUSION

Patients too unwell, unable to report pain, 2 or more category ≥2 PUs.

FOLLOW-UP

Twice weekly for 30 days.

PRIMARY AND SECONDARY OUTCOME MEASURES

Development and time to development of one or more category ≥2 PUs.

RESULTS

Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001).

CONCLUSIONS

This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development.

Reconstructive surgery for treating pressure ulcers

BACKGROUND

The management of pressure ulcers involves several interventions ranging from pressure-relieving measures such as repositioning, to treatments that can include reconstructive surgery. Such surgery may be considered for recalcitrant wounds when full thickness skin loss arises and deeper structures such as muscle fascia and even bone are exposed. The surgery commonly involves wound debridement followed by the addition of new tissue into the wound. Whilst reconstructive surgery is an accepted means of ulcer management, the benefits and harms of surgery compared with non-surgical treatments, or alternative surgical approaches are not clear.

OBJECTIVES

To assess the effects of reconstructive surgery for healing pressure ulcers (stage II or above), comparing surgery with no surgery or comparing alternative forms of surgery in any care setting.

SEARCH METHODS

We searched the following electronic databases to identify reports of relevant randomised clinical trials (searched 26 September 2016): the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. We also searched three clinical trials registers and reference lists of relevant systematic reviews, meta-analyses and health technology assessment reports.

SELECTION CRITERIA

Published or unpublished randomised controlled trials that assessed reconstructive surgery in the treatment of pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias and extract study data.

MAIN RESULTS

We did not identify any studies that met the review eligibility criteria nor any registered studies investigating the role of reconstructive surgery in the management of pressure ulcers.

AUTHORS' CONCLUSIONS

Currently there is no randomised evidence that supports or refutes the role of reconstructive surgery in pressure ulcer management. This is a priority area and there is a need to explore this intervention with more rigorous and robust research.

Do Recipients of an Association-Sponsored Quality Award Program Experience Better Quality Outcomes Compared With Other Nursing Facilities Across the United States?

BACKGROUND

This study explores the relationship between recipients of an association-sponsored Quality Award Program and select measures of quality in U.S. nursing facilities, examined both cross-sectionally and over time.

METHOD

Data used came from Quality Award Program recipients over 9 years (2003-2011) and a set of quality indicators from the Online Survey Certification and Reporting (OSCAR) database. These data were analyzed using a variety of multivariate regression techniques.

RESULTS

Cross-sectionally, the award recipients demonstrated higher performance on most of the quality indicators, compared with both the broader field of nursing facilities and also a more stringent comparison group of facilities. Comparing quality from the 4 years before the award was received to the 4 years after the award, the majority of quality indicators demonstrated improvement in those facilities receiving an award.

CONCLUSION

These results indicate that, in general, the nursing facilities that participate in and receive the Silver or Gold American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) National Quality Award perform at a higher level of quality for residents and sustain that heightened performance over a period of time.

Nursing Homes with Persistent High and Low Quality

This article examines the concentration of low- and high-quality care within particular nursing facilities over time. The authors explore three different explanations for persistent low and high quality over time including the level of public reimbursement, the presence of bed constraint policies such as certificate-of-need and construction moratoria, and the role of consumer information. Using 1991 through 1999 data from the On-Line Survey, Certification, and Reporting system, the authors show that both low- and high-quality nursing home care is concentrated in certain facilities over time. Their results further show that public reimbursement and asymmetric information are both important factors in explaining why low quality persists over time in certain facilities.

Evaluation of physiological risk factors, oxidant-antioxidant imbalance, proteolytic and genetic variations of matrix metalloproteinase-9 in patients with pressure ulcer

Pressure ulcer (PU) remains a common worldwide problem in all health care settings, it is synonymous with suffering. PU is a complex disease that is dependent on a number of interrelated factors. It involves multiple mechanisms such as physiological risk factors, chronic inflammation, oxidant–antioxidant imbalance and proteolytic attack on extracellular matrix by matrix metalloproteinases (MMP). Therefore, we propose that these wounds lead to molecular variations that can be detected by assessing biomarkers. In this study, we aimed to evaluate the major clinical elements and biological scars in Tunisian patients suffering from PU. Consistently, non-healing wound remains a challenging clinical problem. The complex challenges of the wound environment, involving nutrient deficiencies, bacterial infection, as well as the critical role played by inflammatory cells, should be considered because of their negative impact on wound healing. In addition, an imbalance between pro-oxidants and antioxidant systems seems to be more aggravated in patients with PU compared to healthy subjects. Of interest, this study provides further evidence to support a core role of the biological activity of MMP-9 in the pathogenesis of PU and indicates that the MMP9-1562 C/T (rs 3918242) functional polymorphism is associated with protection against this disease.

Antibiotics and antiseptics for pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. A range of treatments with antimicrobial properties, including impregnated dressings, are widely used in the treatment of pressure ulcers. A clear and current overview is required to facilitate decision making regarding use of antiseptic or antibiotic therapies in the treatment of pressure ulcers. This review is one of a suite of Cochrane reviews investigating the use of antiseptics and antibiotics in different types of wounds. It also forms part of a suite of reviews investigating the use of different types of dressings and topical treatments in the treatment of pressure ulcers.

OBJECTIVES

To assess the effects of systemic and topical antibiotics, and topical antiseptics on the healing of infected and uninfected pressure ulcers being treated in any clinical setting.

SEARCH METHODS

In October 2015 we searched: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid EMBASE, and EBSCO CINAHL Plus. We also searched three clinical trials registries and the references of included studies and relevant systematic reviews. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials which enrolled adults with pressure ulcers of stage II or above were included in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included 12 trials (576 participants); 11 had two arms and one had three arms. All assessed topical agents, none looked at systemic antibiotics. The included trials assessed the following antimicrobial agents: povidone iodine, cadexomer iodine, gentian violet, lysozyme, silver dressings, honey, pine resin, polyhexanide, silver sulfadiazine, and nitrofurazone with ethoxy-diaminoacridine. Comparators included a range of other dressings and ointments without antimicrobial properties and alternative antimicrobials. Each comparison had only one trial, participant numbers were low and follow-up times short. The evidence varied from moderate to very low quality.Six trials reported the primary outcome of wound healing. All except one compared an antiseptic with a non-antimicrobial comparator. There was some moderate and low quality evidence that fewer ulcers may heal in the short term when treated with povidone iodine compared with non-antimicrobial alternatives (protease-modulating dressings (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.98) and hydrogel (RR 0.64, 95% CI 0.43 to 0.97)); and no clear difference between povidone iodine and a third non-antimicrobial treatment (hydrocolloid) (low quality evidence). Pine resin salve may heal more pressure ulcers than hydrocolloid (RR 2.83, 95% CI 1.14 to 7.05) (low quality evidence). There is no clear difference between cadexomer iodine and standard care, and between honey a combined antiseptic and antibiotic treatment (very low quality evidence).Six trials reported adverse events (primary safety outcome). Four reported no adverse events; there was very low quality evidence from one showing no clear evidence of a difference between cadexomer iodine and standard care; in one trial it was not clear whether data were appropriately reported.There was limited reporting of secondary outcomes. The five trials that reported change in wound size as a continuous outcome did not report any clear evidence favouring any particular antiseptic/anti-microbial treatments. For bacterial resistance, one trial found some evidence of more MRSA eradication in participants with ulcer treated with a polyhexanide dressing compared with a polyhexanide swab (RR 1.48, 95% CI 1.02 to 2.13); patients in the dressing group also reported less pain (MD -2.03, 95% CI -2.66 to -1.40). There was no clear evidence of a difference between interventions in infection resolution in three other comparisons. Evidence for secondary outcomes varied from moderate to very low quality; where no GRADE assessment was possible we identified substantial limitations which an assessment would have taken into account.

AUTHORS' CONCLUSIONS

The relative effects of systemic and topical antimicrobial treatments on pressure ulcers are not clear. Where differences in wound healing were found, these sometimes favoured the comparator treatment without antimicrobial properties. The trials are small, clinically heterogenous, generally of short duration, and at high or unclear risk of bias. The quality of the evidence ranges from moderate to very low; evidence on all comparisons was subject to some limitations.

Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures

Background

The Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5).

Methods

The programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI).

Key findings

Pain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity.

Conclusions

The PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Alginate dressings for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and there are many options to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use for the treatment of pressure ulcers. This review is part of a suite of Cochrane reviews investigating the use of dressings in the treatment of pressure ulcers. Each review will focus on a particular dressing type.

OBJECTIVES

To assess the effects of alginate dressings for treating pressure ulcers in any care setting.

SEARCH METHODS

For this review, in April 2015 we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of alginate with alternative wound dressings or no dressing in the treatment of pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included six studies (336 participants) in this review; all studies had two arms. The included studies compared alginate dressings with six other interventions that included: hydrocolloid dressings, silver containing alginate dressings, and radiant heat therapy. Each of the six comparisons included just one study and these had limited participant numbers and short follow-up times. All the evidence was of low or very low quality. Where data were available there was no evidence of a difference between alginate dressings and alternative treatments in terms of complete wound healing or adverse events.

AUTHORS' CONCLUSIONS

The relative effects of alginate dressings compared with alternative treatments are unclear. The existing trials are small, of short duration and at risk of bias. Decision makers may wish to consider aspects such as cost of dressings and the wound management properties offered by each dressing type, for example, exudate management.

Negative pressure wound therapy for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Negative pressure wound therapy (NPWT) is a treatment option for pressure ulcers; a clear, current overview of the evidence is required to facilitate decision-making regarding its use.

OBJECTIVES

To assess the effects of negative pressure wound therapy for treating pressure ulcers in any care setting.

SEARCH METHODS

For this review, we searched the following databases in May 2015: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

The review contains four studies with a total of 149 participants. Two studies compared NPWT with dressings; one study compared NPWT with a series of gel treatments and one study compared NPWT with 'moist wound healing'. One study had a 24-week follow-up period, and two had a six-week follow-up period, the follow-up time was unclear for one study. Three of the four included studies were deemed to be at a high risk of bias from one or more 'Risk of bias' domains and all evidence was deemed to be of very low quality. Only one study reported usable primary outcome data (complete wound healing), but this had only 12 participants and there were very few events (only one participant healed in the study). There was little other useful data available from the included studies on positive outcomes such as wound healing or negative outcomes such as adverse events.

AUTHORS' CONCLUSIONS

There is currently no rigorous RCT evidence available regarding the effects of NPWT compared with alternatives for the treatment of pressure ulcers. High uncertainty remains about the potential benefits or harms, or both, of using this treatment for pressure ulcer management.

Hydrogel dressings for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and there are many different dressing options including hydrogel dressings. A clear and current overview of the current evidence is required to facilitate decision-making regarding dressing use for the treatment of pressure ulcers.

OBJECTIVES

To assess the effects of hydrogel dressings on the healing of pressure ulcers in any care setting.

SEARCH METHODS

We searched the following databases: the Cochrane Wounds Group Specialised Register (searched 19 June 2014); The Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 5); Ovid MEDLINE (1946 to June Week 2 2014); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 23 June 2014); Ovid EMBASE (1974 to 20 June 2014); and EBSCO CINAHL (1982 to 18 June 2014). There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of hydrogel dressings with alternative wound dressings or no dressing in the treatment of pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included eleven studies (523 participants) in this review. Ten studies had two arms and one had three arms that were all relevant to this review. Three studies compared a hydrogel dressing with a basic wound contact dressing; three studies compared a hydrogel dressing with a hydrocolloid dressing; three studies compared a hydrogel dressing with another hydrogel dressing; one study compared a hydrogel dressing with a foam dressing; one study compared a hydrogel dressing with a dextranomer paste dressing and one study compared a hydrogel dressing with a topical treatment (collagenase). Limited data were available for analyses in this review: we conducted no meta-analyses. Where data were available there was no evidence of a difference between hydrogel and alternative treatments in terms of complete wound healing or adverse events. One small study reported that using hydrogel dressings was, on average, less costly than hydrocolloid dressings, but this estimate was imprecise and its methodology was not clear. All included studies were small, had short follow-up times and were at unclear risk of bias.

AUTHORS' CONCLUSIONS

It is not clear if hydrogel dressings are more or less effective than other treatments in healing pressure ulcers or if different hydrogels have different effects, Most trials in this field are very small and poorly reported so that risk of bias is unclear.

Factors predicting the development of pressure ulcers in an at-risk population who receive standardized preventive care: secondary analyses of a multicentre randomised controlled trial

AIMS

To identify predictive factors associated with the development of pressure ulcers in patients at risk who receive standardized preventive care.

BACKGROUND

Numerous studies have examined factors that predict risk for pressure ulcer development. Only a few studies identified risk factors associated with pressure ulcer development in hospitalized patients receiving standardized preventive care.

DESIGN

Secondary analyses of data collected in a multicentre randomized controlled trial.

METHODS

The sample consisted of 610 consecutive patients at risk for pressure ulcer development (Braden Score <17) receiving standardized preventive care measures. Patient demographic information, data on skin and risk assessment, medical history and diagnosis were collected during 26 months (December 2007-January 2010). Predictive factors were identified using multivariate statistics.

RESULTS

Pressure ulcers in category II-IV were significantly associated with non-blanchable erythema, urogenital disorders and higher body temperature. Predictive factors significantly associated with superficial pressure ulcers were admission to an internal medicine ward, incontinence-associated dermatitis, non-blanchable erythema and a lower Braden score. Superficial sacral pressure ulcers were significantly associated with incontinence-associated dermatitis.

CONCLUSIONS

Despite the standardized preventive measures they received, hospitalized patients with non-blanchable erythema, urogenital disorders and a higher body temperature were at increased risk for developing pressure ulcers.

RELEVANCE TO CLINICAL PRACTICE

Improved identification of at-risk patients can be achieved by taking into account specific predictive factors. Even if preventive measures are in place, continuous assessment and tailoring of interventions is necessary in all patients at risk. Daily skin observation can be used to continuously monitor the effectiveness of the intervention.

A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development

The aim of this analysis was to identify the association between incontinence-associated dermatitis (IAD), its most important etiologic factors (incontinence and moisture), and pressure ulcers (PUs). A systematic review and meta-analysis were performed. We searched Medline, Embase, CINAHL, Web of Science, and the Cochrane Library for relevant papers dating through March 15, 2013. Fifty-eight studies were included. Measures of relative effect at the univariate level were meta-analyzed. In most studies (86%), a significant association between variables of interest was found, with pooled odds ratios of PUs in univariate models between 1.92 (95% CI 1.54-2.38) for urinary incontinence and 4.99 (95% CI 2.62-9.50) for double incontinence (p < .05). This evidence indicates an association between IAD, its most important etiological factors, and PUs. Methodological issues should be considered when interpreting the results of this review.

Effects of impairment in activities of daily living on predicting mortality following hip fracture surgery in studies using administrative healthcare databases

BACKGROUND

Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative databases lack information on ADL function. We evaluated the impact of ADL function on predicting postoperative mortality among older adults with hip fractures in Ontario, Canada.

METHODS

Sociodemographic and medical correlates of ADL impairment were first identified in a population of older adults with hip fractures who had ADL information available prior to hip fracture. A logistic regression model was developed to predict 360-day postoperative mortality and the predictive ability of this model were compared when ADL impairment was included or omitted from the model.

RESULTS

The study sample (N = 1,329) had a mean age of 85.2 years, were 72.8% female and the majority resided in long-term care (78.5%). Overall, 36.4% of individuals died within 360 days of surgery. After controlling for age, sex, medical comorbidity and medical conditions correlated with ADL impairment, addition of ADL measures improved the logistic regression model for predicting 360 day mortality (AIC = 1706.9 vs. 1695.0; c -statistic = 0.65 vs 0.67; difference in - 2 log likelihood ratios: χ(2) = 16.9, p = 0.002).

CONCLUSIONS

Direct measures of ADL impairment provides additional prognostic information on mortality for older adults with hip fractures even after controlling for medical comorbidity. Observational studies using administrative databases without measures of ADLs may be potentially prone to confounding and bias and case-mix adjustment for hip fracture outcomes should include ADL measures where these are available.

A systematic review of risk factors for the development and recurrence of pressure ulcers in people with spinal cord injuries

STUDY DESIGN

A systematic review was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor (RF) studies.

OBJECTIVES

The literature identifies many RFs for pressure ulcer (PU) recurrence and development; however, RFs independently predictive of PU development in adults with spinal cord injury (SCI) have not been determined. A systematic review was undertaken to identify RFs for PUs for people with SCI.

SETTING

Acute hospital, community and rehabilitation settings.

METHODS

Electronic searches of MEDLINE, EMbase and Cochrane databases from 1980 to 2011 were completed. Retrieved studies were assessed for eligibility and quality criteria applied by two independent reviewers. Identified RFs were categorised into themes and compared and contrasted with RFs identified for the general PU population.

RESULTS

The five studies included 18 RFs. These were classified into six themes: sociodemographic, neurological, functional, clinical, biological and medical care management. RFs for both the general and SCI-specific populations were similar, however, clinical, functional and hospital management emerged as specific RF domains for the SCI population.

CONCLUSION

We identified SCI-specific RFs for the development and recurrence of PUs. However, these findings are based on a small number of studies; highlighting the need for further confirmatory work to reduce PU development and recurrence, and provide a foundation for SCI risk assessment development.

Patient risk factors for pressure ulcer development: systematic review

OBJECTIVE

To identify risk factors independently predictive of pressure ulcer development in adult patient populations?

DESIGN

A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies.

DATA SOURCES

Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction.

REVIEW METHODS

Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken.

RESULTS

Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important.

CONCLUSIONS

Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility.

Outcomes after rectal cancer surgery in elderly nursing home residents

BACKGROUND

As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial.

OBJECTIVE

The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents.

DESIGN

This is a retrospective cohort study.

SETTING

This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services.

PATIENTS

Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were fecal incontinence and the 1-year mortality rate.

RESULTS

Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022).

LIMITATIONS

Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice.

CONCLUSIONS

Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.

Development and validation of a pressure ulcer risk assessment tool for acute hospital patients

The purpose of this study was to develop and validate a pressure ulcer risk assessment for acute hospitals. This tool was developed in a cohort of 342 patients with a mean age 63 years (SD 19.82) and validated in a second cohort of 165 patients with a mean age 68 years (SD 18.40). Risk factors for inclusion on The Northern Hospital Pressure Ulcer Prevention Plan (TNH-PUPP) were identified from the literature then examined and weighted using logistic regression. Risk factors included on the TNH-PUPP were requires assistance to move in bed (odds ratio [OR] 5.15; 95% confidence interval [CI]: 2.49-10.65), admission to intensive care during current admission (OR 2.98; 95% CI: 1.33-6.67), aged ≥ 65 years (OR 2.81; 95% CI: 1.24-6.36), reduced sensation (OR 2.29; 95% CI: 1.19-4.42), and cognitive impairment (OR 2.26; 95% CI: 1.09-4.67). The TNH-PUPP was validated in a prospective sample. The new tool had high diagnostic validity (area under the receiver operating curve=0.86), consistent in the validation sample (area under the receiver operating curve=0.90). The TNH-PUPP has a moderate positive predictive value (development=0.50; validation=0.13), and a high negative predictive value (development=0.94; validation=0.99) enabling low-risk patients to be screened out, as noncandidates for pressure ulcer prevention interventions. An accurate pressure ulcer risk assessment has been developed and validated, which identifies a high-risk group to whom limited pressure ulcer prevention resources should be directed. The TNH-PUPP facilitates effective resource allocation and is likely to reduce unnecessary patient harm and costs from pressure ulcers in acute hospitals.

Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings

Background

In long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention.

Methods

Data for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients.

Results

A data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer.

Conclusions

interRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.