Antje Tannen

The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes

OBJECTIVES Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes. METHODS A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake. RESULTS Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes. CONCLUSION There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.

Differences in prevalence of pressure ulcers between the Netherlands and Germany--associations between risk, prevention and occurrence of pressure ulcers in hospitals and nursing homes.

AIM This study compares pressure ulcer prevalence and prevention activities in nursing homes and hospitals within two European countries. Background. Over three years stable differences have been found between the Netherlands (NL) and Germany (GER) with higher pressure ulcer rates in the NL. As previous analyses have shown, the differences cannot be entirely explained by differences in the populations vulnerability to pressure ulcers because they still remain after risk adjustment. Therefore, the differences in prevalence must be caused by other factors. The purpose of this study is to analyse if any potential differences in preventive activities can account for the varying occurrence of pressure ulcers. METHOD In both countries, nation-wide surveys were conducted annually using the same standardised questionnaires. Trained nurses examined all consenting patients of the voluntarily participating facilities. This examination included a skin assessment of the entire body. Data regarding risk factors, prevention and details about wounds were then collected. RESULTS In-patients of 29 German (n = 2531) and 71 Dutch (n = 10,098) nursing homes and 39 German (n = 8515) and 60 Dutch (n = 10,237) hospitals were investigated. The use of pressure-reducing devices was more common in the NL than in GER, but all other interventions were more frequently provided to German risk patients than to their Dutch counterparts. The pressure ulcer prevalence was significantly higher in the Dutch sample. After adjusting for gender, age, Braden Score and prevention, the probability of having a pressure ulcer was 8.1 times higher for Dutch nursing home residents than for German residents. CONCLUSION Some of the variance in pressure ulcer prevalence between the two countries can be explained by varying pressure ulcer prevention. However, some remarkable differences still remain unexplained. RELEVANCE TO CLINICAL PRACTICE The extent of pressure ulcer prevention, especially repositioning and nutrition intervention provided to patients at risk, is not in accordance with international guidelines.

Mobility is the key! Trends and associations of common care problems in German long-term care facilities from 2008 to 2012

BACKGROUND Although enormous efforts have been made in auditing the quality of care, there are only few epidemiological studies available about the actual occurrence of immobility, malnutrition, urinary incontinence, cognitive impairment, falls and pressure ulcers in long-term care facilities. OBJECTIVE The objective of this study was to provide prevalence estimates of common nursing care problems in long-term care facilities and to investigate any associations between them. DESIGN Secondary data analysis of five consecutive annual cross-sectional multicenter studies from 2008 to 2012. SETTING 262 different long-term care facilities throughout Germany. PARTICIPANTS 14,798 residents older than 18 years who gave informed consent. METHODS Health conditions were rated based on direct resident examinations according to the current international definitions. Demographic characteristics were compared with available national population statistics. Apart from descriptive statistics, Chi(2) tests were carried out for bivariate and log-regression models were performed for multivariate associations. RESULTS Prevalence rates were stable over the years with the highest prevalence of 73.5% (95% CI 72.8-74.2) being found for urinary incontinence, for cognitive impairment it was 54.1% (95% CI 53.3-54.9) and for immobility it was 36.5% (95% CI 35.7-37.3). The lowest prevalence rates were established for the risk of malnutrition with 13.0 (95% CI 12.4-13.5), for pressure ulcers with 4.8% (95% CI 4.5-5.1) and for falls (4.4% 95% CI 4.1-4.8). In the multivariate model, immobility was most strongly associated with all of the other conditions. No statistically significant associations were found between pressure ulcers and falls, pressure ulcers and urinary incontinence, pressure ulcers and cognitive impairment and between malnutrition and urinary incontinence. CONCLUSION Decision-makers and clinical practitioners may primarily focus on the maintenance and enhancement of mobility, because this seems to be the key predictor for many other health conditions in the context of care dependency in the nursing home setting.

Higher pressure ulcer risk on intensive care? – Comparison between general wards and intensive care units

OBJECTIVE The objective of the study was to evaluate the effect of being treated in intensive care units in comparison with general hospital wards regarding pressure ulcer occurrence when controlled for various risk factors. BACKGROUND Pressure ulcer occurrence is commonly used as an indicator for the quality of care. Large-scale incidence studies are costly and difficult to perform. DESIGN Secondary analysis of patient data (n = 32,400) collected during 2002-2009 as part of eight multicentre pressure ulcer surveys in 256 German hospitals. METHODS Ward-acquired pressure ulcer rate was used for the calculation of effect sizes as a surrogate parameter for pressure ulcer incidence. The SRISAG (surface, repositioning, immobility, shear forces, age, gender) logistic regression model was used to control for differences in case mix. RESULTS Pressure ulcer prevention and intrinsic and extrinsic risk factors differ for patients from hospital wards compared with those from intensive care wards. The ward-acquired pressure ulcer rate in general hospital wards was 3·9% (1·5% excluding grade 1). In intensive care, the rate was 14·9% (8·5% excluding grade 1), which corresponds with an unadjusted odds ratio of 4·3 (95%CI 3·8-4·9). After the SRISAG model was applied, the odds ratio was reduced to 1·5 (CI 1·2-1·7). CONCLUSION When surface, repositioning, immobility, shear forces, age and gender are controlled for the institutional factor intensive care unit vs. general hospital wards is no longer a high-risk factor for the development of pressure ulcer. The SRISAG model is simple and can be used to compare the occurrence of pressure ulcer between different medical specialties. RELEVANCE TO CLINICAL PRACTICE Application of this model allows more valuable comparison of the occurrence of pressure ulcer in different specialities and enables clinical practitioners and health care planners to use this outcome as an indicator for the quality of care to avoid confounding.

Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany – adjusted for personal risk factors and institutional quality indicators

BACKGROUND Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence. METHODS Data of a binational multi-centred cross-sectional study in 103 hospitals (n = 21,378 patients) and 129 nursing homes (n = 15,579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators. RESULTS The prevalence of pressure ulcers among the at-risk group (Bradenscore <or=20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2-5.7)]. In hospitals, the prevalence among the at-risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2-1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0-9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4-3.0). CONCLUSION A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.

Hospital pressure ulcer prevalence rates and number of raters.

AIM The purpose of this study was to evaluate the influence of different numbers of nurse raters conducting skin inspection (one or two) on observed pressure ulcer prevalence rates. BACKGROUND Pressure ulcer prevalence and incidence rates are important outcome measures for the quality of care. To ensure reliability and comparability of such rates standardisation of study methods is recommended. It is assumed that data accuracy can be improved if skin inspection is conducted by a team of two raters. DESIGN A secondary data analysis of pressure ulcer prevalence data was conducted. METHOD Groups of hospital patients which were examined by one (n = 2420) or two raters (n = 15,009) were compared regarding demographic characteristics, pressure ulcer risk and pressure ulcer prevalence. Logistic regressions were conducted to examine the association between the number of raters (one or two) and the outcome pressure ulcer (yes/no). RESULTS Groups of one and two raters were comparable regarding demographic characteristics. There was no statistically significant difference regarding pressure ulcer prevalence between both groups (p = 0.222). There was no relation between the number of raters and the probability of identifying a pressure ulcer patient (p = 0.060). CONCLUSIONS Pressure ulcer prevalence rates in the analysed studies were not affected by the number of raters. There seems to be no relation between the numbers of nurses conducting skin inspection and observed prevalence rates. RELEVANCE TO CLINICAL PRACTICE Conducting pressure ulcer prevalence studies require a lot of effort and personal costs. Provided that one nurse alone or a team of two nurses rate the existence of pressure ulcers equally it is no longer obligatory to have two raters. This would save resources. However, when patients are restricted in their mobility two nurses are recommended to provide assistance in patient turning.

Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison

AIM Comparison of the diagnostic accuracy of two pressure ulcer risk assessment scales and one generic nursing assessment tool. BACKGROUND Guidelines for pressure ulcer prevention recommend an initial risk screening of all patients, followed by appropriate nursing interventions. Additionally, personal and financial resources have to be allocated carefully to avoid excessive or too little treatment. Risk assessments should be accurate and applicable, and some studies showed that generic nursing tools also provide specific information for nursing diagnoses, like risk for pressure ulcer. DESIGN Cross sectional observational study. METHODS A total of 1053 adult patients of a university hospital in Germany were investigated. For each patient, the Braden Scale, the Waterlow Scale and the Care Dependency Scale were completed. A skin inspection was conducted by trained nurses. Correlations between the three scales and the mean values of each pressure ulcer risk assessment scales for each Care Dependency Scale value were calculated. To determine the association between susceptibility to pressure ulcer and observed pressure ulcer, the area under the curve was calculated. RESULTS There was a higher correlation between the Braden Scale and the Care Dependency Scale (r = 0.82) than between the two pressure ulcer risk assessment scales (-0.65). The highest area under the curve was reached by the Braden Scale (0.86), followed by the Care Dependency Scale (0.83) and the Waterlow Scale (0.81). Only the Braden Scale (cut-off 18) and the Care Dependency Scale (cut-off 65) reached the psychometric requirements of at least 70% sensitivity and 70% specificity. CONCLUSIONS The Care Dependency Scale could be used for both a general nursing assessment and as a screening tool for risk for pressure ulcers. The Braden Scale showed the highest association with the occurrence of pressure ulcer. RELEVANCE TO CLINICAL PRACTICE The Care Dependency Scale is a useful screening tool to identify patients at risk for pressure ulcers. Nursing assessment activities might be reduced by using a generic nursing assessment tool also for specific risk screening.

Care problems and nursing interventions related to oral intake in German Nursing homes and hospitals: A descriptive mulitcentre study

BACKGROUND Reduced nutritional intake in care-dependent patients is a risk factor for malnutrition. The prevalence of malnutrition has been extensively reported, but there is little empirical data on the prevalence of the underlying causes of reduced oral intake and the extent of nursing interventions that address malnutrition. OBJECTIVES To report the prevalence of problems that potentially led to decreased nutritional intake. To investigate the association between these problems and body mass index (BMI). To investigate the association between increased care dependency and BMI. To document nutrition-related interventions. DESIGN Cross-sectional multicentre study. SETTING A total of 15 hospitals (H) and 76 nursing homes (NH) in Germany were included. PARTICIPANTS A total of 2930 hospital patients and 5521 nursing home residents were included in the study. The mean age was 66.6 ± 16.7 years (in H) and 84.9 ± 9.8 years (in NH); 14.7% (in H) and 50.4% (in NH) were almost or completely care dependent. A BMI ≤ 20kg/m² was found in 8.5% (in H) and 16.7% (in NH). RESULTS Most hospital patients were eating and drinking independently (72.2%), whereas 58.4% of the nursing home residents needed assistance. Major problems in hospitals were polypharmacy (18.6%), loss of appetite (14.6%) and pain (7.8%); in nursing home common problems were functional problems of the upper extremities (17%), loss of appetite (15.5%) and polypharmacy (15.5%). Patients with a high level of care dependency had higher rates of BMI ≤ 20kg/m². In both settings (H and NH), BMI ≤ 20kg/m² was significantly associated with loss of appetite (odds ratio (OR) 2.6, 95%CI 1.9-3.5 and OR 7.0, 95%CI 5.9-8.3), nausea (OR 2.1, 95%CI 1.3-3.3 and OR 2.8, 95%CI 1.9-4.1), chewing problems (OR 2.1, 95%CI 1.2-3.4 and OR 2.5, 95%CI 2.1-3.1) and swallowing problems (OR 2.3, 95%CI 1.4-3.6 and OR 2.3, 95%CI 1.9-2.8). Nutrition-related nursing interventions were employed more frequently in nursing homes than in hospitals. CONCLUSION A high care dependency in general and in terms of eating and drinking should be addressed in daily care to ensure sufficient nutritional intake. Additional problems, such as loss of appetite, should also be addressed with suitable interventions to prevent malnutrition. Nutrition-related interventions need to be increased in German health care facilities.

Malnutrition in Austrian hospital patients. Prevalence, risk factors, nursing interventions, and quality indicators: a descriptive multicentre study

AIMS This study reports the prevalence of malnutrition (according to body mass index and malnutrition universal screening tool) and the prevalence of health problems that may influence the development of malnutrition in Austrian hospitals. Screening routines and nutrition-related interventions on patient level and quality indicators on ward and facility levels were also investigated. BACKGROUND Malnutrition is an undesirable condition of care-dependent patients and can increase morbidity and mortality of those affected; it is therefore required to screen every patient to detect people at risk and treat them early. Only little data are available on the prevalence of the underlying causes and on the extent of nutrition-related interventions. DESIGN A cross-sectional multicentre study in 11 Austrian hospitals (n = 2,283) in 2009. METHODS Every patient was assessed by two trained nurses. Data were collected using a standardized validated questionnaire. RESULTS/FINDINGS The prevalence of malnutrition according to the malnutrition universal screening tool was 15·7% (high risk) and 8·3% (middle risk). A body mass index <20·0 kg/m² was found in 12·0% (6% <18·5 kg/m²). Main problems were loss of appetite (56·6%), acute disease (38·6%), and nausea (22·3%). About 70% of the patients were screened on admission. Patients at risk were referred to a nutritional expert (7-28·7%), received protein-energy-enriched diets (2·5-15·1%) or snacks (5·1-17·4%). A dietician was available in all hospitals; 8/11 hospitals had fixed criteria for assessing malnutrition; guideline policy varied among the facilities. CONCLUSION The majority of wards acted in compliance with clinical guidelines; nevertheless, there are still some facilities that do not screen and weigh their patients in a standardized manner and do not treat high-risk patients adequately.

Pressure Ulcer, the Scale of the Problem

The main goal of this chapter is to provide information about the frequency of pressure ulcers. However, in doing this it becomes evident that the chapter title— the scale of the problem—should really be amended to the problem of the scale. Due to the different rates used (prevalence, incidence), different grades/stages of pressure ulcers (1, 2, 3, 4), different body sites, different settings (hospital, nursing home, at home) and different ways of data collection it is almost impossible to find comparable data about the scale of this phenomenon in human beings. Therefore, this chapter should be regarded more as a guide on how to deal with data on pressure ulcers obtained from the literature. First, information is provided about the use of rates and their application to pressure ulcers. Then some suggestions are given about how to interpret the figures from the literature.