Jan Kottner

Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed.

OBJECTIVE Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need for rigorously conducted interrater and intrarater reliability and agreement studies. Information about sample selection, study design, and statistical analysis is often incomplete. Because of inadequate reporting, interpretation and synthesis of study results are often difficult. Widely accepted criteria, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies. STUDY DESIGN AND SETTING Eight experts in reliability and agreement investigation developed guidelines for reporting. RESULTS Fifteen issues that should be addressed when reliability and agreement are reported are proposed. The issues correspond to the headings usually used in publications. CONCLUSION The proposed guidelines intend to improve the quality of reporting.

Maintaining skin integrity in the aged: a systematic review

Ageing is associated with structural and functional changes of the skin that result in increased vulnerability. The aim of this systematic review is to synthesize empirical evidence about the efficacy and effectiveness of basic skin care interventions for maintaining skin integrity in the aged. The databases Medline, EMBASE, CINAHL (1990–2012), Scopus, SCI (February 2013) and reference lists were searched. Inclusion criteria were primary intervention studies using skin care products in physiologically aged skin (lower age limit 50 years). Study and sample characteristics, interventions and outcomes were extracted. The methodological quality was assessed and a level of evidence was assigned. From 1535 screened articles 188 were read in full text. From these, 33 articles were included reporting results on treating dry skin conditions, and preventing incontinence‐associated dermatitis and superficial ulcerations. Most studies had lower levels of evidence of 3 or 4. Skin‐cleansing products containing syndets or amphoteric surfactants compared with standard soap and water washing improved skin dryness and demonstrated skin‐protecting effects. Moisturizers containing humectants consistently showed statistically significant improvements in skin dryness. Skin barrier products containing occlusives reduced the occurrence of skin injuries compared with standard or no treatment. Owing to methodological limitations the current evidence base for basic skin care in the aged is weak. Using low‐irritating cleansing products and humectant‐ or occlusive‐containing moisturizers seems to be the best strategy for maintaining the skin barrier function and integrity. We know little about the effects of cleansing regimens and about the benefits of moisturizers when compared with each other.

Recommendations for reporting the results of studies of instrument and scale development and testing.

Scales and instruments play an important role in health research and practice. It is important that studies that report on their psychometric properties do so in a way such that readers can understand what was done and what was found. This paper is a guide to writing articles about the development and assessment of these tools. It covers what should be in the abstract and how key words should be chosen. The article then discusses what should be in the main parts of the paper: the introduction, methods, results and discussion. In each of these parts, it suggests the statistical tests that should be used and how to report them. The emphasis throughout the paper is that reliability and validity are not fixed properties of a scale, but depend on an interaction among it, the population being evaluated and the circumstances under which the instrument is administered.

The trend of pressure ulcer prevalence rates in German hospitals: Results of seven cross-sectional studies

Pressure ulcer prevalence rates provide useful information about the magnitude of this health problem. Only limited information on pressure ulcers in Germany was available before 2001. The purpose of this study was to compare results of seven pressure ulcer prevalence surveys which were conducted annually between 2001 and 2007 and to explore whether pressure ulcer prevalence rates decreased. The second aim was to evaluate if the measured prevalence rates of our sample could be generalised for all German hospitals. Results of seven point pressure ulcer prevalence studies conducted in 225 German hospitals were analysed. Chi-square tests, chi-square trend tests and one-way ANOVA to assess differences and trends across the years were applied. The sample was stratified according to pressure ulcer risk and speciality. Finally, study samples were compared with the potential population. In total data of 40,247 hospital patients were analysed. The overall pressure ulcer prevalence rate in German hospitals was 10.2%. Patient samples of each year were comparable regarding gender, age and pressure ulcer risk. Pressure ulcer prevalence rates decreased from 13.9% (year 2001) to 7.3% (year 2007) (p<0.001). When excluding non-blanchable erythema prevalence rates decreased from 6.4% (year 2001) to 3.9% (year 2007) (p=0.015). An explicit decrease of prevalence rates was observed on geriatric wards. Prevalence rates on neurological and intensive care units remained stable. With some limitations our study results are representative for all hospitals within Germany. It is highly probable that the decrease of prevalence rates was due to an increased awareness of the pressure ulcer problem in Germany and subsequent efforts to improve pressure ulcer prevention and treatment. The quality of clinical practice regarding pressure ulcer prevention and treatment has improved. However, pressure ulcers are still relevant and require attention. In 2007, one out of 10 hospital patients who were at pressure ulcer risk had at least one pressure related skin damage.

A systematic review of interrater reliability of pressure ulcer classification systems

AIMS To review systematically the interrater reliability of pressure ulcer classification systems to find out which classification should be used in daily practice. BACKGROUND Pressure ulcer classification systems are important tools in research and practice. They aim at providing accurate and precise communication, documentation and treatment decisions. Pressure ulcer classifications are criticised for their low degree of interrater reliability. DESIGN Systematic review. METHODS The data bases MEDLINE, EMBASE, CINAHL and the World Wide Web were searched. Original research studies estimating interrater reliability of pressure ulcer classification systems were included. Study selection, data extraction and quality assessment was conducted independently by two reviewers. RESULTS Twenty-four out of 339 potentially relevant studies were included in the final data synthesis. Due to the heterogeneity of the studies a meaningful comparison was impossible. CONCLUSIONS There is at present not enough evidence to recommend a specific pressure ulcer classification system for use in daily practice. Interrater reliability studies are required, in which comparable raters apply different pressure ulcer classification systems to comparable samples. RELEVANCE TO CLINICAL PRACTICE It is necessary to determine the interrater reliability of pressure ulcer classifications among all users in clinical practice. If interrater reliability is low the use of those systems is questionable. On the basis of this review there are no recommendations as to which system is to be given preference.

Weight and pressure ulcer occurrence: A secondary data analysis

BACKGROUND Prolonged external mechanical loads lead to compression, tension and shear of the skin and underlying tissues leading to pressure ulcers. Underweight seems to be associated with high pressure ulcer risk but the distinct relation between overweight and pressure ulcer development is uncertain. Anatomical and physiological differences of typical pressure ulcer points are often neglected. OBJECTIVES (1) Is there a relationship between BMI and superficial (category 2) and deep (category 3/4) pressure ulcers on the trunk? (2) Is there a relationship between BMI and superficial (category 2) and deep (category 3/4) pressure ulcers at the heels? DESIGN Secondary data analysis of ten pressure ulcer prevalence surveys in Germany. Comparison of proportions of pressure ulcer patients according to the 12 BMI groups provided by the WHO considering superficial and deep pressure ulcers and different anatomic locations. SETTING AND SAMPLE Hospital patients (n=50,446). Median age was 68 (IQR 55-78) years and the proportion of female patients was 55.4%. RESULTS The overall proportion of patients with at least one pressure ulcer at the trunk was 2.0% (99% CI 1.8-2.2) for category 2 and 0.9% (99% CI 0.8-1.0) for category 3/4 pressure ulcers. Trunk pressure ulcer proportions were significantly higher in thin individuals than in normal weight and obese patients. The overall proportion of patients with at least one heel pressure ulcer was 0.6% (99% CI 0.5-0.7) for category 2 and 0.6% (99% CI 0.5-0.7) for category 3/4. With one exception there were no statistically significant differences between BMI groups. CONCLUSIONS Irrespective of the degree of mobility and activity thin patients are at higher risk for pressure ulcers at the sacrum, ischial tuberosity, trochanter and shoulder than normal weight and obese patients. Heel pressure ulcers seem to be unrelated to the BMI level, indicating that the BMI is not a predictor for heel PU development. These results also support the assumption that the etiology and pathogenetic mechanisms of trunk and heel PU development might be partially different. Pressure ulcer risk models might need to be redesigned because distinct risk factors only apply to distinct anatomic locations.

Frequency of pressure ulcers in the paediatric population: A literature review and new empirical data

BACKGROUND Published pressure ulcer incidence and prevalence figures in the paediatric population vary widely. The frequency of pressure ulcers in the German paediatric population is unknown. Currently, a systematic synthesis of PU incidence and prevalence studies in paediatric settings is missing. OBJECTIVES To determine the prevalence and incidence of pressure ulcers in the paediatric population and the anatomic sites that are most often affected; and whether pressure ulcer occurrence in German paediatric hospital samples is comparable to international figures. DESIGN A systematic literature review and a secondary data analysis were conducted. METHODS The MEDLINE und CINAHL databases were searched. Methodological quality of relevant studies was systematically evaluated, relevant data extracted and synthesised. Data from five German-wide pressure ulcer prevalence studies were analysed. RESULTS In total, 19 studies were identified containing any information about pressure ulcer frequency in the paediatric population. Methodological quality of many studies was low. Taking only higher quality studies into account, pressure ulcer incidence was approximately 7% in the total paediatric population and 26% in the ICU setting. Prevalence estimates varied between 2% and 28%. Excluding grade 1 pressure ulcers, prevalence ranged from 1% to 5%. Especially in newborns and infants, the head was most often affected by pressure injuries. Many pressure ulcers were caused by medical devices. In Germany, pressure ulcer prevalence grade 1-4 in the general paediatric population was 2.3% (95% CI 1.4-3.6%). Excluding grade 1 pressure ulcer, prevalence was 0.8% (95% CI 0.4-1.8%). CONCLUSIONS Due to considerable methodological limitations and insufficient reporting there is a dearth of sound empirical evidence about pressure ulcer frequency in the paediatric population. Conducting and reporting of future studies must be improved. Pressure ulcer prevalence in German hospital samples was comparable to international figures. Newborns, infants, and small children are at higher risk to develop pressure ulcers at the occipital region as compared to other anatomic locations. The likelihood of developing sacral and heel pressure ulcers increases with increasing age and growth.

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.

Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review

BACKGROUND Pressure ulcer risk assessment using an age-appropriate, valid and reliable tool is recommended for clinical paediatric practice. OBJECTIVES (1) What PU risk scales for children currently exist? (2) What is the diagnostic accuracy of their scores? (3) Are the scores reliable and what is the degree of agreement? (4) What is the clinical impact of risk scale scores in paediatric practice? DESIGN Systematic review. DATA SOURCES MEDLINE (1950 to December 2010), EMBASE (1989 to December 2010), CINAHL (1982 to December 2010), reference lists. REVIEW METHODS Two reviewers independently screened databases, selected and evaluated articles and studies. Diagnostic accuracy, reliability/agreement, and experimental studies investigating the performance and clinical impact of PU risk scale scores in the paediatric population (0-18 years) were included. PU development was used as reference standard for diagnostic accuracy studies. Methodological quality of the validity and reliability studies was assessed based on the QUADAS and QAREL checklists. RESULTS The search yielded 1141 hints. Finally, 15 publications describing or applying 12 paediatric pressure ulcer risk scales were included. Three of these scales (Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown, Braden Q Scale, Burn Pressure Skin Risk Assessment Scale) were investigated in prospective validation studies. Empirical evidence about interrater reliability and agreement is available for four instruments (Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown, Starkid Skin Scale, Glamorgan Scale, Burn Pressure Ulcer Risk Assessment Scale). No studies were identified investigating the clinical impact. CONCLUSIONS Sound empirical evidence about the performance of paediatric pressure ulcer risk assessment scales is lacking. Based on the few results of this review no instrument can be regarded as superior to the others. Whether the application of pressure ulcer risk assessment scales reduces the pressure ulcer incidence in paediatric practice is unknown. Maybe clinical judgement is more efficient in evaluating pressure ulcer risk than the application of risk scale scores.

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.