Katrin Balzer

Do pressure ulcer risk assessment scales improve clinical practice

Standardized assessment instruments are deemed important for estimating pressure ulcer risk. Today, more than 40 so-called pressure ulcer risk assessment scales are available but still there is an ongoing debate about their usefulness. From a measurement point of view pressure ulcer (PU) risk assessment scales have serious limitations. Empirical evidence supporting the validity of PU risk assessment scale scores is weak and obtained scores contain varying amounts of measurement error. The concept of pressure ulcer risk is strongly related to the general health status and severity of illness. A clinical impact due do the application of these scales could also not be demonstrated. It is questionable whether completion of standardized pressure ulcer risk scales in clinical practice is really needed.

Falls prevention for the elderly

Background An ageing population, a growing prevalence of chronic diseases and limited financial resources for health care underpin the importance of prevention of disabling health disorders and care dependency in the elderly. A wide variety of measures is generally available for the prevention of falls and fall-related injuries. The spectrum ranges from diagnostic procedures for identifying individuals at risk of falling to complex interventions for the removal or reduction of identified risk factors. However, the clinical and economic effectiveness of the majority of recommended strategies for fall prevention is unclear. Against this background, the literature analyses in this HTA report aim to support decision-making for effective and efficient fall prevention. Research questions The pivotal research question addresses the effectiveness of single interventions and complex programmes for the prevention of falls and fall-related injuries. The target population are the elderly (> 60 years), living in their own housing or in long term care facilities. Further research questions refer to the cost-effectiveness of fall prevention measures, and their ethical, social and legal implications. Methods Systematic literature searches were performed in 31 databases covering the publication period from January 2003 to January 2010. While the effectiveness of interventions is solely assessed on the basis of randomised controlled trials (RCT), the assessment of the effectiveness of diagnostic procedures also considers prospective accuracy studies. In order to clarify social, ethical and legal aspects all studies deemed relevant with regard to content were taken into consideration, irrespective of their study design. Study selection and critical appraisal were conducted by two independent assessors. Due to clinical heterogeneity of the studies no meta-analyses were performed. Results Out of 12,000 references retrieved by literature searches, 184 meet the inclusion criteria. However, to a variable degree the validity of their results must be rated as compromised due to different biasing factors. In summary, it appears that the performance of tests or the application of parameters to identify individuals at risk of falling yields little or no clinically relevant information. Positive effects of exercise interventions may be expected in relatively young and healthy seniors, while studies indicate opposite effects in the fragile elderly. For this specific vulnerable population the modification of the housing environment shows protective effects. A low number of studies, low quality of studies or inconsistent results lead to the conclusion that the effectiveness of the following interventions has to be rated unclear yet: correction of vision disorders, modification of psychotropic medication, vitamin D supplementation, nutritional supplements, psychological interventions, education of nursing personnel, multiple and multifactorial programs as well as the application of hip protectors. For the context of the German health care system the economic evaluations of fall prevention retrieved by the literature searches yield very few useful results. Cost-effectiveness calculations of fall prevention are mostly based on weak effectiveness data as well as on epidemiological and cost data from foreign health care systems. Ethical analysis demonstrates ambivalent views of the target population concerning fall risk and the necessity of fall prevention. The willingness to take up preventive measures depends on a variety of personal factors, the quality of information, guidance and decision-making, the prevention program itself and social support. The analysis of papers regarding legal issues shows three main challenges: the uncertainty of which standard of care has to be expected with regard to fall prevention, the necessity to consider the specific conditions of every single case when measures for fall prevention are applied, and the difficulty to balance the rights to autonomous decision making and physical integrity. Discussion and conclusions The assessment of clinical effectiveness of interventions for fall prevention is complicated by inherent methodological problems (esp. absence of blinding) and meaningful clinical heterogeneity of available studies. Therefore meta-analyses are not appropriate, and single study results are difficult to interpret. Both problems also impair the informative value of economic analyses. With this background it has to be stated that current recommendations regarding fall prevention in the elderly are not fully supported by scientific evidence. In particular, for the generation of new recommendations the dependency of probable effects on specific characteristics of the target populations or care settings should be taken into consideration. This also applies to the variable factors influencing the willingness of the target population to take up and pursue preventive measures. In the planning of future studies equal weight should be placed on methodological rigour (freedom from biases) and transferability of results into routine care. Economic analyses require input of German data, either in form of a “piggy back study“ or in form of a modelling study that reflects the structures of the German health care system and is based on German epidemiological and cost data.

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.

Pflegeabhängigkeit im Pflegeheim--eine psychometrische Studie

Zusammenfassung. Ein niederländisches Instrument zur Erfassung der Pflegeabhängigkeit wurde ins Deutsche übersetzt und hinsichtlich verschiedener Gütekriterien überprüft. Es wurden gute Ergebnisse erzielt für die Reliabilität und Validität. Die Skala kann für die Anwendung im Altenheim empfohlen werden. Zukünftige weitere methodologische Prüfungen werden empfohlen.Summary.The Dutch Care Dependency Scale, an instrument for the assessment of a patient’s care dependency, has been translated into German. The purpose of this study was to examine the reliability and validity of the German version of the scale. The 15-item scale has been developed for the use in nursing homes. Data were collected from 81 people living in nursing homes in Berlin, Germany. The sample was measured three times. Cronbach’s alpha was 0.94. Interrater and intrarater reliability revealed moderate to substantial Kappa statistics. As the results of this study were satisfying, positive recommendations regarding the suitability of the German version of the Care Dependency Scale for use in nursing homes could be made. However, further psychometric testing of the scale is recommended.

Medical specialist attendance in nursing homes

The care in nursing homes was examined based on scientific studies. The analysis focuses on dementia and type II diabetes. There is evidence for deficits in the supply of medical specialist attendance to nursing home residents with these diseases in Germany. Compared with corresponding guidelines the medical care for nursing home residents may be too low or inadequate.

Evidenzbasierte Pflegepraxis–Diskussionsbeitrag zum Status quo

To what extent is evidence-based nursing practice (EBP) implemented in Germany? What do nurses know about EBP, and are they willing to engage in EBP? Which barriers exist, and how could we manage to overcome them? These and other questions are discussed in the current contribution that ends with an outline of the prerequisites for a successful long-term implementation of EBP.

Care dependency in nursing home : a psychometric study

Zusammenfassung. Ein niederländisches Instrument zur Erfassung der Pflegeabhängigkeit wurde ins Deutsche übersetzt und hinsichtlich verschiedener Gütekriterien überprüft. Es wurden gute Ergebnisse erzielt für die Reliabilität und Validität. Die Skala kann für die Anwendung im Altenheim empfohlen werden. Zukünftige weitere methodologische Prüfungen werden empfohlen.Summary.The Dutch Care Dependency Scale, an instrument for the assessment of a patient’s care dependency, has been translated into German. The purpose of this study was to examine the reliability and validity of the German version of the scale. The 15-item scale has been developed for the use in nursing homes. Data were collected from 81 people living in nursing homes in Berlin, Germany. The sample was measured three times. Cronbach’s alpha was 0.94. Interrater and intrarater reliability revealed moderate to substantial Kappa statistics. As the results of this study were satisfying, positive recommendations regarding the suitability of the German version of the Care Dependency Scale for use in nursing homes could be made. However, further psychometric testing of the scale is recommended.

Core outcome sets in dermatology: report from the second meeting of the International Cochrane Skin Group Core Outcome Set Initiative

Results of clinical trials are the most important information source for generating external clinical evidence. The use of different outcomes across trials, which investigate similar interventions for similar patient groups, significantly limits the interpretation, comparability and clinical application of trial results. Core outcome sets (COSs) aim to overcome this limitation. A COS is an agreed standardized collection of outcomes that should be measured and reported in all clinical trials for a specific clinical condition. The Core Outcome Set Initiative within the Cochrane Skin Group (CSG‐COUSIN) supports the development of core outcomes in dermatology.

Improving competencies in evidence-based dementia care: Results from a pilot study on a novel inter-professional training course (the KOMPIDEM project).

Objective: In order to address well-known challenges in dementia care, an inter-professional course was developed to improve medical students’ and nursing students’ competencies in the provision of evidence-based care for people with dementia. The course comprises lectures, problem-based learning (PbL) tutorials and visitations to care facilities. A pilot study was conducted to evaluate the acceptance and feasibility of the inter-professional course. Methodology: Alongside preliminary implementation of the newly developed course, a pre-post survey was carried out involving all participating students. The questionnaire contained standardized and open-ended questions on participants’ views regarding the quality and relevance of several course components and characteristics. The data were analyzed by means of descriptive statistics. Results: When the course was offered the first time, multiple barriers became evident, leading to premature course termination and subsequent revision of the curriculum. When the revised course was offered, 10 medical students and 8 nursing students participated. The course proved feasible, and the median overall quality was rated as “2” (IQR 2–3) at a rating scale ranging from 1 (very good) to 6 (inadequate). Following aspects were most frequently judged positively: the course’s inter-professional scope, the visitations to care facilities and the PbL tutorials. Potential for improvement was particularly noted with regard to a more distinct focus on well-defined, mainly practical learning outcomes. There were no indications of systematic between-group differences in the medical and nursing students’ perceptions of the course program. Conclusions: The results confirmed the feasibility of the inter-professional course on dementia care and the relevance of its inter-professional scope. However, to ensure sustainable course implementation in the long term, further program adaptations based on current findings and further evaluation studies focusing on objective parameters of the process and outcome quality are required.

NICE recommendation on the use of pressure ulcer risk scores is flawed

The updated National Institute for Health and Care Excellence guideline on preventing pressure ulcers claims to reflect current evidence.1 However, its recommendation on assessing pressure ulcer risk is surely not evidence based. For risk assessment in adults, health professionals are advised to “consider using a validated scale to support clinical judgment.”1 This recommendation is mainly based on expert opinion—the …