Irene Maier

Predicting pressure ulcer risk: a multifactorial approach to assess risk factors in a large university hospital population

AIMS The purpose of this study was: (1) to determine the combination of risk factors which best predicts the risk of developing pressure ulcers among inpatients in an acute care university hospital; (2) to determine the appropriate weight for each risk factor; and (3) to derive a concise and easy-to-use risk assessment tool for daily use by nursing staff. BACKGROUND Efficient application of preventive measures against pressure ulcers requires the identification of patients at risk. Adequate risk assessment tools are still needed because the predictive value of existing tools is sometimes unsatisfactory. DESIGN Survey. METHODS A sample of 34,238 cases admitted to Essen University Clinics from April 2003 and discharged up to and including March 2004, was enrolled into the study. Nursing staff recorded data on pressure ulcer status and potential risk factors on admission. Predictors were identified and weighted by multivariate logistic regression. We derived a risk assessment scale from the final logistic regression model by assigning point values to each predictor according to its individual weight. RESULTS The period prevalence rate of pressure ulcers was 1.8% (625 cases). The analysis identified 12 predictors for developing pressure ulcers. With the optimum cut-off point sensitivity and specificity were 83.4 and 83.1%, respectively, with a positive predictive value of 8.4% and a negative predictive value of 99.6%. The diagnostic probabilities of the derived scale were similar to those of the original regression model. CONCLUSIONS The predictors mostly correspond to those used in established scales, although the use of weighted factors is a partly novel approach. Both the final regression model and the derived scale show good prognostic validity. RELEVANCE TO CLINICAL PRACTICE The derived risk assessment scale is an easy-to-understand, easy-to-use tool with good prognostic validity and can assist in effective application of preventive measures against pressure ulcer.

Prevalence of Pressure Ulcers in Hospitalized Patients in Germany in 2005: Data from the Federal Statistical Office

Objective: Using the National Statistics (‘DRG-Statistik’) published by the Federal Statistical Office, we analyzed prevalences of pressure ulcers coded as principal or as additional diagnosis separately and describe differences in ulcer characteristics. Patients and Methods: Age-adjusted prevalence and tables for gender and age distribution of pressure ulcers separately for the principal diagnosis and for additional diagnoses were provided by the Federal Statistical Office. Results: In 2005, about 16 million patients were treated as full-time patients in German hospitals. 9,941 (0.06%) were referred with pressure ulcer as principal diagnosis and 191,040 (1.19%) had at least one additional diagnosis pressure ulcer. People >65 years of age had the highest risk for pressure ulcers (per 100,000 population principal diagnosis: females 52 and males 37; additional diagnosis: females 1,076 and males 947). Up to 80% of those who had the principal diagnosis pressure ulcer had ulcers grade 3 and 4, whereas 60% of the pressure ulcers documented as additional diagnosis were grade 1 and 2 (p < 0.001). The most frequent localizations of pressure ulcers were the ischium, the sacrum and the heel. In patients <65 years of age with the principal diagnosis pressure ulcer, the mortality rate is <0.1%. In the older age groups it increases gradually up to 10% in the 8th decade of life. Conclusion: Pressure ulcers are still a relevant problem in Germany. Although patients 65 years and older are at the highest risk, all age groups are affected. Younger people seem to struggle with different problems compared to older people.

Prevention of pressure ulcer: interaction of body characteristics and different mattresses

We analysed the effect of different body features on contact area, interface pressure and pressure distribution of three different mattresses. Thirty‐eight volunteers (age ranged from 17 to 73 years, 23 females) were asked to lie on three different mattresses in a random order: I, standard hospital foam mattresses; II, higher specification foam mattresses (Viscorelax Sure®); III, constant low pressure devices (CareMedx®, AirSystems). Measurements were performed in supine position and in a 90° left‐ and right‐sided position, respectively, using a full‐body mat (pressure mapping device Xsensor X2‐Modell). Outcome variables were contact area (CA) in cm2, mean interface pressure (IP) in mmHg and pressure distribution (PD) estimated as rate of low pressures between 5 and 33 mmHg on each mattress in percent. Mean CA was lowest in the standard hospital foam mattresses and increased in the higher specification foam mattresses and was highest in the constant low pressure device (supine position: 491 ± 86 cm2, 615 ± 95 cm2, 685 ± 116 cm2). Mean IP was highest in the standard hospital foam mattresses and lower but similar in the higher specification foam mattresses and the constant low pressure devices (supine position: 22·3 ± 1·5 mmHg, 17·6 ± 1·7 mmHg, 17·6 ± 2·2 mmHg). Models were estimated for CA, IP and PD including the independent variables height, weight and waist‐to‐hip‐ratio (WHR). They show that body morphology seems to play a minor role for CA, IP and PD, but very thin and tall patients and very small and obese people might benefit from different mattresses. Our data show that CA increases with increasing specification of mattresses. Higher specification foam mattresses and constant low pressure devices show similar IP, but constant low pressure devices show a wider pressure distribution. Body morphology should be considered to optimise prevention for single patients.

Increasing pressure ulcer rates and changes in delivery of care: a retrospective analysis at a University Clinic

AIM To evaluate the relation between pressure ulcers and delivery of care. BACKGROUND No decrease of pressure ulcer rates could be recognised in acute hospital care, despite intensive efforts in prevention. Furthermore, reports show increasing rates. DESIGN Retrospective analysis of hospital data. METHODS The study included all inpatients from year 1 (2003/2004) and 4 (2006/2007) of the interdisciplinary decubitus project. Information on ulcers was recorded at admission, discharge and in case of new events. We analysed the effect of age, length of stay, operation and intensive care episode. In logistic regression, we used the existence of ulcers and the appearance of new ulcers as dependent variables. RESULTS Parallel to a decrease in the number of inpatients, age, length of stay and operation frequency rose between 2003 and 2007. Higher age, longer length of stay, operation, intensive care episode and year 4 raise the odds for ulcers in univariate and with exception of operation in multivariate analyses. With exception of operation and year 4, the same variables raise the odds for new ulcers, too. CONCLUSIONS The increase of pressure ulcer frequency could be related to changes in delivery of care. The adverse event pressure ulcer will become more important in hospital care. RELEVANCE TO CLINICAL PRACTICE There is no decrease in pressure ulcer rates, albeit enormous efforts in prevention. Hospital care has been facing changes in case mix. Age, length of stay and intensive care episodes are related to increasing ulcer rates at a University Clinic. Nursing management has to be aware of additional workload for pressure ulcer management in the future.