Pressure ulcers among patients admitted to home care

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.

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

BACKGROUND

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery.

METHODS

A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System.

RESULTS

Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition.

CONCLUSION

The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

Healing Time of Skin Ulcers in Homecare Residents in the Province of Reggio Emilia, Northern Italy

The growing phenomenon of skin ulcers represents an important health problem; therefore, we conducted a pilot study to evaluate the ulcer healing time among adult subjects followed by the Home Nursing Service of the AUSL-IRCCS of Reggio Emilia, Northern Italy, and diagnosed with at least one skin ulcer during the period of January-August 2020. We recruited 138 subjects (45.5% men) with a mean age of 86.1 years. The subjects presented with 232 ulcers, of which 76.7% were pressure ulcers (60.1% were stage II), 18.1% were vascular ulcers, and 4.7% were diabetic foot ulcers. Ulcer management required only one weekly access for the majority of subjects, with a recovery frequency of 53.6% at the end of the observation period. The median ulcer healing time was 3.6 months and was shorter in women (2.6 months) than men (5.1 months), with an increasing trend according to the number of ulcers and the severity of pressure ulcers for vascular and diabetic foot ulcers. In conclusion, this is the first study carried out in an Italian population describing the distribution and characteristics of homecare residents with skin ulcers and highlighting the factors influencing the healing time and as consequence the duration of nursing care.

External Locking Plate Fixation for Femoral Subtrochanteric Fractures

Introduction

Internal fixation is the treatment of choice for subtrochanteric fractures in most conditions. However, it may be an unsuitable procedure for patients with poor health status, osteomyelitis, and surrounding soft tissue compromise. This study aimed to ascertain the viability and reliability of using external locking plate fixation for these difficult cases.

Methods

Eleven patients with femoral subtrochanteric fractures who received external locking plate fixation in our institute from January 2014 to December 2019 were enrolled in our study. The bone union time, wound complication, alignment, and necessity for narcotic agents were evaluated.

Results

The average length of follow-up was 17.5 months (range, 14-26 months). The mean time for bone union was 17.7 weeks (range, 15-21 weeks). The indications included poor health condition, soft tissue compromise, and post-operative osteomyelitis. Pin tract infection was noted in two patients who were treated successfully with oral antibiotics administration and removal of the involved screws. Osseous union with varus deformity <10° was achieved in all patients except one. Three patients required an orally administered pain killer at the final visit. The average Harris Hip Score at one year post-operatively was 66.6 (range, 49-80).

Conclusions

Although the current study only involved 11 patients, we believe that our method may serve as a valuable alternative for the treatment of a femoral subtrochanteric fracture in selected cases.

Level of Evidence

Level IV, retrospective case series.

An overview of co-morbidities and the development of pressure ulcers among older adults

Background

The prevalence of pressure ulcers particularly in the frail older adult population continues to be high and very costly especially in those suffering from chronic diseases and has brought a higher awareness to comprehensive, preventive and therapeutic measures for treatment of pressure ulcers. Internal risk factors highlighted by comorbidities play a crucial role in the pathogenesis of pressure ulcers.

Main body

Focusing on the impact of common chronic diseases (comorbidities) in aging on pressure ulcers (e.g., cardiovascular diseases, diabetes, chronic pulmonary diseases, renal diseases and neurodegenerative disorders) and the significant complicating conditions e.g., anemia, infectious diseases, malnutrition, hospitalization, incontinence and polypharmacy, frailty and disability becomes important in developing a more complete, inclusive and multidisciplinary approach to prevention of PU in older patients.

Objective

To describe chronic and acute conditions which are risk factors in elderly patients for developing PU.

Methods

We present an overview of comorbidities seen with PU in three diverse patient locations.

The inclusion criteria are sites (community, acute hospital and long term facilities), older patients, chronic diseases and pressure ulcers grade 2 and over.

Using a recently developed conceptual framework accepted by European and National Pressure Ulcer Advisory Panels, we examined chronic diseases to identify the risk factors of chronic conditions and complicating conditions which potentially influence risk for PU development.

Conclusion

Multiple chronic diseases and complicating factors which associated with immobility, tissue ischemia, and undernutrition are caused to PU in community settings, hospitals, and nursing facilities.

Longitudinal Outcomes of Home Care in Korea to Manage Pressure Ulcers

Home care provides preventive, support, and treatment services to economically vulnerable community populations. In this study, we examined the outcomes of a home care program for pressure ulcers (PrUs) in an economically vulnerable group. The 184 participants were admitted with PrUs and received services from a home care agency in South Korea during a study window of 5 years. The changes in PrU staging over time were analyzed in relation to the agency's home care data and the participants' health data. At enrollment, approximately 60% had a single ulcer; 40% had two or more. Most patients' ulcers were at stages 3 or 4, and most patients were bedridden. The maximum odds of reduced ulcer size from one measurement point to the next was estimated at 14.3% for ulcers in stages 1 and 2, 33.4% of those in stage 3, and 25.5% of those in stage 4; more than 10% of ulcers healed completely within a year. PrUs were a serious problem in this community-dwelling economically vulnerable group, and home care played a critical role in providing health care to this population. © 2017 Wiley Periodicals, Inc.

Developing a Wound Management Orientation Program Using Evidence-Based Guidelines

Staff development specialists and certified wound, ostomy, continence nurses must be leaders in the design of orientation programs that will assist nurses new to the practice of home health care develop wound care management skills. An orientation developed on evidence-based practice is essential to ensure quality, safe patient outcomes, and positive fiscal outcomes. This article describes the basic elements essential to a comprehensive orientation and suggests several models to assist the orientee in developing competency in wound care.

Legal Issues in Home Care: Current Trends, Risk-Reduction Strategies, and Opportunities for Improvement

Home health nurse malpractice litigation and judgments are increasing. The legal and home health practice environments are evolving in streams of tumultuous change. The legal view of nurse practice lags behind the realities of nurse practice. Evidence-based practice is evolving and becoming the expected standard of practice. This article summarizes the current home health malpractice trends and identifies current factors affecting change in both the legal and home health environments. Strategies and resources to reduce nurse malpractice risk in home care are discussed.

Pressure ulcers: Current understanding and newer modalities of treatment

This article reviews the mechanism, symptoms, causes, severity, diagnosis, prevention and present recommendations for surgical as well as non-surgical management of pressure ulcers. Particular focus has been placed on the current understandings and the newer modalities for the treatment of pressure ulcers. The paper also covers the role of nutrition and pressure-release devices such as cushions and mattresses as a part of the treatment algorithm for preventing and quick healing process of these wounds. Pressure ulcers develop primarily from pressure and shear; are progressive in nature and most frequently found in bedridden, chair bound or immobile people. They often develop in people who have been hospitalised for a long time generally for a different problem and increase the overall time as well as cost of hospitalisation that have detrimental effects on patient's quality of life. Loss of sensation compounds the problem manifold, and failure of reactive hyperaemia cycle of the pressure prone area remains the most important aetiopathology. Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper. The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.

Pressure Ulcer Risk Assessment

This article is a report on a study to develop a pressure ulcer risk assessment scale for home care clients. Multiple linear regressions were used to model scores on the Braden assessment scale and subcales, using data from the Resident Assessment Instrument—Home Care (RAI-HC) assessment. In Phase 1, data from 510 home care clients who received both assessments within a 14-day period were used to develop the models. Suitable “proxy Braden” models were constructed for the Braden scale and all subscales except for the nutrition subscale. In Phase 2, receiver operating curves revealed the proxy Braden to be a significantly better predictor than the RAI-HC Pressure Ulcer Risk Scale (PURS) of pressure ulcer development in home care clients.

Effect of influenza on functional decline

OBJECTIVES

To examine the relationship between influenza and activity of daily living (ADL) decline and other clinical indicators in nursing home (NH) residents.

DESIGN

Retrospective NH-aggregated longitudinal study.

SETTING

Two thousand three hundred fifty-one NHs in 122 U.S. cities from 1999 to 2005.

PARTICIPANTS

Long-stay (>90 days) NH residents.

MEASUREMENTS

Quarterly city-level influenza mortality and state-level influenza severity. Quarterly incidence of Minimum Data Set-derived ADL decline (≥ 4 points), weight loss, new or worsening pressure ulcers (PUs), and infections. Outcome variables chosen as clinical controls were antipsychotic use, restraint use, and persistent pain.

RESULTS

City-level influenza mortality and state-level influenza severity were associated with higher rates of large (≥ 4 points) ADL decline (mortality β = 0.20, P < .001; severity β = 0.18, P < .001), weight loss (β = 0.19, P < .001; β = 0.24, P < .001), worsening PUs (β = 0.04, P = .08; β = 0.12, P < .001), and infections (β = 0.41, P < .001; β = 0.47, P < .001) but not with restraint use, antipsychotic use, or persistent pain. NH influenza vaccination rates were weakly associated with the outcomes (e.g., β = -0.009, P = .03 for ADL decline, β = 0.008, P = .07 for infections). Compared with the summer quarter of lowest influenza activity, the results for the other quarters translate to an additional 12,284 NH residents experiencing large ADL decline annually, 15,168 experiencing significant weight loss, 6,284 new or worsening PUs, and 29,753 experiencing infections due to influenza.

CONCLUSION

The results suggest a substantial and potentially costly effect of influenza on NH residents. The effect of influenza vaccination on preventing further ADL decline and other clinical outcomes in NH residents should be studied further.

Avaliação da concordância na aplicação da Escala de Braden interobservadores

OBJETIVOS: Verificar a prevalência de úlcera por pressão nas unidades de internação de pacientes adultos do Hospital Universitário da Universidade de São Paulo (HU-USP) e verificar a concordância entre observadores na avaliação de risco, por meio da Escala de Braden. MÉTODOS: Estudo exploratório, quantitativo. Os dados foram coletados por seis colaboradoras treinadas que realizaram exame físico e avaliação de risco em 87 pacientes, avaliação esta considerada "padrão ouro". Os dados das avaliações feitas pelas enfermeiras, nos mesmos pacientes, foram coletados dos prontuários. RESULTADOS: verificou-se prevalência de 19,5% no hospital e 63,6% na Unidade de Terapia Intensiva, 15,6% na Clínica Cirúrgica, 13,9% na Clínica Médica e 0% na Semi-Intensiva. Quanto à concordância entre os observadores na avaliação clínica dos pacientes, a percepção sensorial, atividade, mobilidade e fricção/cisalhamento apresentaram fortíssima concordância. Umidade e nutrição, baixa concordância, sugerindo que esses subescores deverão ser discutidos para verificar as causas da controvérsia. CONCLUSÃO: Estudos de prevalência de úlcera por pressão possibilitam verificar a extensão do problema e fornecem subsídios para construção de estratégias e programas de prevenção.

Colonization of pressure ulcers by multidrug-resistant microorganisms in patients receiving home care

Colonization and/or infection with multidrug-resistant microorganisms (MDRO) of pressure ulcers in patients receiving care at home have seldom been investigated. The objective of this study was to assess the prevalence of MDRO colonization in pressure ulcers of patients receiving home care in Palermo, Italy. Vancomycin-resistant Enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and multidrug-resistant Gram-negative bacilli (MDRGN) were isolated, identified, and characterized from pressure ulcers and selected home environment surfaces. Thirty-two patients were enrolled, of whom 12 were under antimicrobial therapy. Five patients had been admitted to hospital in the preceding year. Nineteen patients tested positive for 1 or more MDROs. In particular, 1 patient was colonized by a vanA-containing strain of VRE, 5 by MRSA, and 17 by MDRGN of different species. Our findings suggest that pressure ulcers in home care patients could play a role in bringing MDROs into the community setting.

Effect of lysine hyaluronate on the healing of decubitus ulcers in rehabilitation patients

INTRODUCTION

Chronically hospitalized patients are often burdened with skin ulcerations, which may be persistent and even irreversible. Treatment with hyaluronic acid is widely used in the early phases of the ulcers to relieve symptoms and accelerate the healing process. The present study hypothesized that lysine hyaluronate (Lys-HA) (Lysial(®), Fatai-Nyl Srl; Jasper LLC, Lugano, Switzerland), a new formulation of hyaluronic acid, would improve the healing of decubitus ulcers more than the commonly used sodium hyaluronate (SH). A double-blind randomized controlled trial was designed to assess the superiority of Lys-HA versus SH on decubitus ulcer size reduction over a 15-day period, and on the time necessary to reach 50% lesion size regression.

METHODS

After a clinical evaluation, 50 hospitalized patients with decubitus ulcers were divided into three groups according to ulcer stage (stage 1: erythema and edema; stage 2: all-thickness skin destruction; stage 3: destruction of subcutaneous tissue) and randomized to receive Lys-HA or SH. Digital photographs were taken before the start of treatment, then every 3 days, and at the end of the study. Pre- and posttreatment differences in each group were tested using Student t tests and analysis of covariance with basis values as covariates.

RESULTS

Ulcer reduction was greater in all the Lys-HA groups than SH groups. In stage 1 patients, 90% and 70% lesion size reductions were observed in the groups allocated to Lys-HA and SH, respectively (P<0.05). In stage 2 patients, 70% and 40% lesion size reductions were observed in the Lys-HA and SH groups, respectively (P<0.02). In stage 3 patients, 71% and 29% lesion size reductions were observed in the Lys-HA and SH groups, respectively (P<0.01). The regression time of 50% of lesion size was shorter in all the Lys-HA groups than SH groups (P<0.05).

CONCLUSION

The use of Lys-HA in the healing process of decubitus ulcers provides an improved efficacy with respect to SH in hospitalized patients, suggesting its use from the early phases of ulceration.

Keeping vulnerable elderly patients free from pressure ulcer is associated with high caregiver burden in informal caregivers

RATIONALE AND OBJECTIVES

The effect of the presence of pressure ulcers on burden of caregivers is unknown. We investigated the relationship between the state of pressure ulcers in vulnerable elderly patients and the burden on their informal caregivers.

METHODS

This cross-sectional study enrolled 137 patients aged > or = 40 years with limited activity and mobility at 10 home care service facilities in Japan. We assessed pressure ulcer status from medical records and caregiver burden using scores from both the Burden Index of Caregivers (BIC) and the Japanese short version of the Zarit Burden Interview (ZBI).

RESULTS

Among patients, mean age was 80.9 years, 31.4% were men, and 83.9% were free from pressure ulcers. Multivariable analysis showed that caregivers whose patients were free from pressure ulcers had significantly higher caregiver burden as assessed by both the BIC [beta-coefficient = 3.18, 95% confidence interval (CI): 1.42-4.95, P = 0.003] and ZBI scores (beta-coefficient = 1.94; 95%CI = 0.30-3.58; P = 0.03).

CONCLUSIONS

Our results suggest that the continuous effort involved in keeping patients free from pressure ulcers may be associated with high caregiver burden in informal caregivers.

Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice

AIMS AND OBJECTIVES

To investigate the pressure ulcer prevalence in home nursing patients and to evaluate guideline adherence of measures for the prevention of pressure ulcers and the participation of informal carers in pressure ulcer prevention.

BACKGROUND

Since 2002, the Belgian Guideline for the Prevention of Pressure Ulcers was published on the Internet, but no information was available on guideline adherence in home care.

METHODS

A cross-sectional survey of pressure ulcer prevalence and guideline adherence was performed in a cluster randomized sample of 2779 clients of nine regional nursing departments in Flanders, Belgium. The Belgian Guideline for the Prevention of Pressure Ulcers was the reference standard for the evaluation of the guideline adherence.

RESULTS

There were 744 subjects at risk for developing pressure ulcers. The overall prevalence of pressure ulcers for the total sample population was 6.8%. The age-, sex- and risk-standardized prevalence per regional department varied between 4.9% and 9.1%. Of the 744 subjects at risk, 33 (4.4%) received preventive measures, which were in adherence to the Belgian Guideline for Prevention of Pressure Ulcers, 482 persons (64.8%) were administered measures, which did not adhere to the Belgian Guideline for Prevention of Pressure Ulcers and in 229 subjects (30.8%) at risk for developing pressure ulcers, prevention was lacking. For subjects with at least one pressure ulcer, the proportions were: 4.8% adherence, 76.6% no adherence and 18.6% no prevention. A proportion of 22.2% of the patients at risk and their informal carers were informed and motivated by the home care nurse to participate in the pressure ulcer prevention and their actual participation in the prevention was 21.4% of all risk cases.

CONCLUSIONS

The adherence of nurses and clients to the guideline for pressure ulcer prevention was low. RELEVANCE TO THE CLINICAL PRACTICE: The study demonstrates a detailed evaluation of guideline adherence to pressure ulcer prevention in an individual patient situation, with special attention for materials and measures, which are not adequate and not recommended by the Belgian Guideline for the Prevention of Pressure Ulcers.

Factors Influencing Pressure Ulcer Healing in Adults Over 50: An Exploratory Study

OBJECTIVE

The purpose of this study was to determine which demographic, clinical, and treatment factors influenced chronic pressure ulcer healing, and to identify the implications for pressure ulcer care being delivered in skilled nursing facilities.

DESIGN

A multisite retrospective chart review was conducted using a structured data abstraction form and protocol.

SETTING

Data collection took place in 3 geographically disperse areas of the country, with subjects having received wound care in hospitals, clinics, nursing homes, and home care.

PARTICIPANTS

Subjects whose charts were reviewed were 50 years of age or older, had at least 1 diagnosed chronic pressure ulcer, and had 3 to 6 months of data available for abstraction. Stage I ulcers were excluded from the analysis.

MEASURES

The structured data collection form included demographics, clinical variables, wound characteristics, and outcomes. The variables ulcer size, exudate type and amount, and necrotic tissue type were combined into a single wound severity score.

RESULTS

Bivariate analyses showed that insurance type, secondary diagnoses of cardiovascular disease and pulmonary disease, initial ulcer size and stage, dressing type changes, use of topical antiseptics, type of debridement, category of dressing, use of hydrocolloid or wet-to-dry dressings, antibiotic administration, and appropriateness of selected dressing and management of necrosis were all significantly associated with healing within 6 months. Logistic regression models identified the following as the most significant predictors of healing: Medicaid, secondary diagnosis of cardiovascular disease, dressing type changed, topical antiseptics, antibiotic administration, pressure relief device, lack of exudate management dressing for moderate or large exudate wound, and lack of debridement of wounds with yellow slough, all decreased the odds of healing; use of exudate management dressings on wounds with no documented exudate increased the odds of healing.

CONCLUSION

Pressure ulcer healing rates overall could be improved if clinicians better matched the characteristics of the wound with the decision to debride and the selection of the optimal dressing. Healing within nursing homes might be improved with less use of enzymatic debridement and antibiotics and more frequent application of hydrocolloid dressings.

Develop A Seamless Individualized Pressure Ulcer Care Plan: Recognize–Understand–Solve

The prevalence of pressure ulcers in patients has been recognized as a quality of care indicator. The suffering and expense resulting from this mostly preventable condition requires a more aggressive approach to both the prevention and treatment of pressure ulcers. Government regulations require planning for the next level of care for the at-risk patient in a clinically and financially effective manner.

PEG-Ernährung bei fortgeschrittener Demenz

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient's will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.

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.

L’escarre à l’hôpital en 2003 : enquête de prévalence un jour donné

BACKGROUND

To determine the prevalence of pressure sores in a university hospital and to assess the risk of developing a pressure sore.

METHODS

A one-day survey was performed in all hospitalized patients, day hospital excepted. The Garches scale was used to assess the severity of pressure sores and the Braden scale was used to measure the patient's risk for the development of pressure ulcers.

RESULTS

One thousand six hundred and eleven patients were included, mean age was 62+/-23 years and 53.3% were over 65 years old. In hospitalized patients, 64% were in acute care, 29% in intermediate medicine and long-term care and 7% in intensive care units. We have found 675 pressure sores in 268 patients, mean age of 76 years; 263 decubitus ulcers were acquired during hospitalization. The most frequent sites were heels (46%) and sacrum (26%). Stage 1 pressure ulcers showed 33% of the total. The total prevalence was 16.6%, 95% CI (14.9-18.6), the hospital acquired pressure sores prevalence was 7.5%, all stages included. A Braden score less than or equal to 15 was found in 29.1% of hospitalized patients. Standard mattresses were used in 37% of patients with pressure sores. Multivariate analysis showed that age and a Braden score less than or equal to 15 were significantly associated with pressure sores.

CONCLUSION

Pressure sores are still an important problem in hospital; occurrence must be considered as an iatrogenic event and management requires a multidisciplinary approach.

Factors Associated with Pressure Ulcers in Palliative Home Care

BACKGROUND

Studies have identified factors associated with pressure ulcers in many health care settings including acute care, complex continuing care, long-term care, and home care.

OBJECTIVE

The purpose of this study was to identify factors associated with pressure ulcers among palliative home care clients. Identifying associations specific to each setting is important for ulcer prevention and has implications for clients overall well-being and quality of life.

METHODS

The study included all palliative home care clients diagnosed with terminal cancer from one palliative home care agency in Ontario. Information on health was gathered using the interRAI instrument for palliative care.

RESULTS

The study found male gender, the inability to lie flat because of shortness of breath, catheter, or ostomy care, and a reduced ability to perform activities of daily living to be associated with pressure ulcers.

SIGNIFICANCE OF RESULTS

In some instances, treatment and prevention of pressure ulcers is the primary goal of care. However, pressure ulcers are also suggestive of deterioration and considered as a part of the disease trajectory. Sometimes the primary goal of care of treatment and prevention is displaced by a greater need for comfort.

Reliability of Electronic Versus Manual Wound Measurement Techniques

OBJECTIVE

To compare the accuracy and reliability of 3 wound measurement techniques, including linear and 2 electronic techniques--Visitrak and the VeV MD system.

DESIGN

Repeated measures involving forty 2-dimensional "wounds" with a range of clinically relevant sizes were created using regular paper. Blinded observers measured the surface areas of wounds in 2 sessions, using 3 techniques.

SETTING

Research department of a tertiary referral center.

PARTICIPANTS

Four blinded observers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mixed linear models were fitted to determine interobserver and intraobserver variability. The average root mean square error (RMSE) for each measurement technique was determined to investigate the accuracy.

RESULTS

Intraobserver variation was not significant in most measurement techniques. Interobserver variation was significant for all techniques. Linear measurements showed the highest RMSE, whereas VeV and Visitrak were comparable.

CONCLUSIONS

Reliability of repeated wound measurements for all techniques can be achieved only with the same observer. Linear measurement has the least accuracy in evaluating wound size, VeV is slightly better than Visitrak for large wounds, and Visitrak is slightly better than VeV for small wounds. Our study shows that the use of electronic devices is superior to manual techniques to achieve valid measurements of wound area.

The quality of pressure ulcer prediction and prevention in home health care

The purpose of this study was to assess the quality of pressure ulcer prediction and prevention in home health care. Randomly selected Medicare-certified home care agencies in four midwestern states were surveyed. The overall response rate was 44% (n = 128). Approximately half (57.8%) of the responding agencies assessed all patients for pressure ulcer risk upon admission; another 4.7% assessed only chair or bed-bound patients. Clinical nursing judgment was the most commonly (72%) used method for assessing risk; only 21% of the agencies used a validated tool such as the Braden Scale or the Norton Scale to identify those at risk. Approximately one third of the reporting agencies had prediction and/or prevention policies. Only 18.0% of home health care agencies identified recommended interventions in a pressure ulcer prevention protocol. Findings suggest opportunities for improvement in pressure ulcer prediction and prevention practice in home health care.

Care planning for pressure ulcers in hospice: The team effect

Objective: The standards of care for patients at risk for or with a pressure ulcer in hospitals and nursing homes focus on prevention and ulcer healing using an interdisciplinary approach. Although not a primary hospice condition, pressure ulcers are not uncommon in dying patients. Their management in hospices, particularly the involvement of family caregivers, has not been studied. The objective of this study is to identify the factors that influence care planning for the prevention and treatment of pressure ulcers in hospice patients and develop a taxonomy to use for further study.

Methods: A telephone survey was conducted with 18 hospice directors of clinical services and 10 direct-care nurses. Descriptive qualitative data analysis using grounded theory was utilized.

Results: The following three themes were identified: (1) the primary role of the hospice nurse is an educator rather than a wound care provider; (2) hospice providers perceive the barriers and burdens of family caregiver involvement in pressure ulcer care to be bodily location of the pressure ulcer, unpleasant wound characteristics, fear of causing pain, guilt, and having to acknowledge the dying process when a new pressure ulcer develops; and (3) the “team effect” describes the collaboration between family caregivers and the health care providers to establish individualized achievable goals of care ranging from pressure ulcer prevention to acceptance of a pressure ulcer and symptom palliation.

Significance of results: Pressure ulcer care planning is a model of collaborative decision making between family caregivers and hospice providers for a condition that occurs as a secondary condition in hospice. A pressure ulcer places significant burdens on family caregivers distinct from common end-of-life symptoms whose treatment is directed at the patient. Because the goals of pressure ulcer care appear to be individualized for a dying patient and their caregivers, the basis of quality-of-care evaluations should be the process of care rather than the outcome of an incident pressure ulcer.

The influence of a change in medicare reimbursement on the effectiveness of stage III or greater decubitus ulcer home health nursing care

This study was designed to describe and evaluate the influence of a change in a Medicare reimbursement on the effectiveness of home health nursing care for stage III or greater decubitus ulcer patients. This health policy originated from the Balanced Budget Act (BBA) of 1997 and took its full effect with initiation of the Prospective Payment System (PPS) on October 1, 2000. A quantitative quasi-experimental design used OASIS data from the state of Virginia to evaluate 555 stage III or greater decubitus ulcer patients, age 65 or older. Comparisons were investigated between pre-PPS, 2000, and post-PPS, 2001, outcomes related to reported ulcer healing, lengths of stay, and discharge disposition. Results demonstrated significant differences for the outcomes studied. In addition, sanitation, ulcer healing, and discharge disposition were linked as predictors for length of stay. Results demonstrated that PPS has affected nursing care effectiveness for stage III or greater decubitus ulcer home health patients.

A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3–4 pressure ulcers: A pilot study

OBJECTIVES

Pressure ulcers, like other chronic wounds, fail to proceed through an orderly and timely process to produce anatomical or functional integrity. Treatment of pressure ulcers is directed to improving host factors and providing an optimum wound environment. In addition to providing a moist wound environment, it has been theorized that preventing hypothermia in a wound and maintaining a normothermic state might improve wound healing.

DESIGN/SETTING

Forty-one subjects with a stage 3 or stage 4 truncal pressure ulcer >1.0 cm(2) were recruited from outpatient clinics, long-term care nursing homes, and a rehabilitation center. The experimental group was randomized to a radiant-heat dressing device and the control group was randomized to a hydrocolloid dressing, with or without a calcium alginate filler. Subjects were followed until healed or for 12 weeks.

RESULTS

Eight subjects (57%) in the experimental group had complete healing of their pressure ulcer compared with 7 subjects (44%) with complete healing in the control group (P = .46).

CONCLUSION

Although a 13% difference in healing rate between the two arms of the study was found, this difference was not statistically significant. At almost all points along the healing curve, the proportion not healed was higher in the control arm.

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.

The growing problem of pressure ulcers. Evaluation and management for an aging population

Pressure ulcers, an important concern in older adults with restricted mobility, promise to become an even bigger issue as the US population ages. These ulcers can lead to devastating complications and place demands on an already stressed healthcare system. They also can be a quality indicator of the preventive measures taken in healthcare facilities. In this article, Drs Dharmarajan and Ahmed present guidelines for the prevention and treatment of pressure ulcers.

Pressure ulcer prediction in older adults receiving home health care: implications for use with the OASIS

OBJECTIVE

To determine whether admission data routinely collected on the Outcome and Assessment Information Set (OASIS) might be used to identify the older adult at risk for pressure ulcer development in home health care.

DESIGN

Secondary analysis of data from a retrospective cohort study.

SETTING AND SUBJECTS

The sample included 1711 nonhospice patients 60 years or older and free of pressure ulcers who were admitted to the intermittent skilled nursing division of a large midwestern home health care agency between January 1995 and March 1996.

MAIN OUTCOME MEASURES

Data on potential risk factors were extracted from admission information. Those identical to items on the admission OASIS assessment were included in the study. Patient records were followed forward chronologically to either pressure ulcer development or absence.

MAIN RESULTS

Cox regression analysis showed that limitation in activity to bed, dependence in dressing, urinary incontinence, and needing assistance with transferring predicted Stage I pressure ulcer development (P </=.001). Bowel/bladder incontinence, oxygen use, a current fracture, and dependence in dressing predicted Stage II and greater pressure ulcer development (P </=.001). Predictors of Stage I plus Stage II and greater pressure ulcers included those predictors from each of the individual models, including limitation in activity to bed, dependence in dressing, a current fracture, oxygen use, needing assistance with transferring, and urinary incontinence (P </=.001).

CONCLUSION

These findings suggest that the admission OASIS assessment may provide a method for identifying elderly patients who are at risk for developing Stage I and Stage II pressure ulcers in home health care.

Setting up a dedicated pressure ulcer unit in a geriatric ward

A geriatric hospital in Israel set up a unit for older patients with pressure ulcers who had other serious, sometimes terminal, conditions. A one-year follow-up study showed overall improvements in their condition and number of ulcers.