Lisette Schoonhoven

Impact of Pressure Ulcers on Quality of Life in Older Patients: A Systematic Review

OBJECTIVES: To identify the impact of pressure ulcers (PUs) and PU interventions on health‐related quality of life (HRQL).

Patient risk factors for pressure ulcer development: Systematic review

OBJECTIVE To identify risk factors independently predictive of pressure ulcer development in adult patient populations? DESIGN A systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies. DATA SOURCES Fourteen electronic databases were searched, each from inception until March 2010, with hand searching of specialist journals and conference proceedings; contact with experts and a citation search. There was no language restriction. REVIEW METHODS Abstracts were screened, reviewed against the eligibility criteria, data extracted and quality appraised by at least one reviewer and checked by a second. Where necessary, statistical review was undertaken. We developed an assessment framework and quality classification based upon guidelines for assessing quality and methodological considerations in the analysis, meta-analysis and publication of observational studies. Studies were classified as high, moderate, low and very low quality. Risk factors were categorised into risk factor domains and sub-domains. Evidence tables were generated and a summary narrative synthesis by sub-domain and domain was undertaken. RESULTS Of 5462 abstracts retrieved, 365 were identified as potentially eligible and 54 fulfilled the eligibility criteria. The 54 studies included 34,449 patients and acute and community patient populations. Seventeen studies were classified as high or moderate quality, whilst 37 studies (68.5%) had inadequate numbers of pressure ulcers and other methodological limitations. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status. Skin moisture, age, haematological measures, nutrition and general health status are also important, but did not emerge as frequently as the three main domains. Body temperature and immunity may be important but require further confirmatory research. There is limited evidence that either race or gender is important. CONCLUSIONS Overall there is no single factor which can explain pressure ulcer risk, rather a complex interplay of factors which increase the probability of pressure ulcer development. The review highlights the limitations of over-interpretation of results from individual studies and the benefits of reviewing results from a number of studies to develop a more reliable overall assessment of factors which are important in affecting patient susceptibility.

Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology

BackgroundCurrent human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.Methods/DesignA multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.DiscussionRN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.

Improving patient handovers from hospital to primary care: a systematic review.

BACKGROUND Evidence shows that suboptimum handovers at hospital discharge lead to increased rehospitalizations and decreased quality of health care. PURPOSE To systematically review interventions that aim to improve patient discharge from hospital to primary care. DATA SOURCES PubMed, CINAHL, PsycInfo, the Cochrane Library, and EMBASE were searched for studies published between January 1990 and March 2011. STUDY SELECTION Randomized, controlled trials of interventions that aimed to improve handovers between hospital and primary care providers at hospital discharge. DATA EXTRACTION Two reviewers independently abstracted data on study objectives, setting and design, intervention characteristics, and outcomes. Studies were categorized according to methodological quality, sample size, intervention characteristics, outcome, statistical significance, and direction of effects. DATA SYNTHESIS Of the 36 included studies, 25 (69.4%) had statistically significant effects in favor of the intervention group and 34 (94.4%) described multicomponent interventions. Effective interventions included medication reconciliation; electronic tools to facilitate quick, clear, and structured summary generation; discharge planning; shared involvement in follow-up by hospital and community care providers; use of electronic discharge notifications; and Web-based access to discharge information for general practitioners. Statistically significant effects were mostly found in reducing hospital use (for example, rehospitalizations), improvement of continuity of care (for example, accurate discharge information), and improvement of patient status after discharge (for example, satisfaction). LIMITATIONS Heterogeneity of the interventions and study characteristics made meta-analysis impossible. Most studies had diffuse aims and poor descriptions of the specific intervention components. CONCLUSION Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects. PRIMARY FUNDING SOURCE The European Union, the Framework Programme of the European Commission.

Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study

Objectives To develop and validate a delirium prediction model for adult intensive care patients and determine its additional value compared with prediction by caregivers. Design Observational multicentre study. Setting Five intensive care units in the Netherlands (two university hospitals and three university affiliated teaching hospitals). Participants 3056 intensive care patients aged 18 years or over. Main outcome measure Development of delirium (defined as at least one positive delirium screening) during patients’ stay in intensive care. Results The model was developed using 1613 consecutive intensive care patients in one hospital and temporally validated using 549 patients from the same hospital. For external validation, data were collected from 894 patients in four other hospitals. The prediction (PRE-DELIRIC) model contains 10 risk factors—age, APACHE-II score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentration, and urgent admission. The model had an area under the receiver operating characteristics curve of 0.87 (95% confidence interval 0.85 to 0.89) and 0.86 after bootstrapping. Temporal validation and external validation resulted in areas under the curve of 0.89 (0.86 to 0.92) and 0.84 (0.82 to 0.87). The pooled area under the receiver operating characteristics curve (n=3056) was 0.85 (0.84 to 0.87). The area under the curve for nurses’ and physicians’ predictions (n=124) was significantly lower at 0.59 (0.49 to 0.70) for both. Conclusion The PRE-DELIRIC model for intensive care patients consists of 10 risk factors that are readily available within 24 hours after intensive care admission and has a high predictive value. Clinical prediction by nurses and physicians performed significantly worse. The model allows for early prediction of delirium and initiation of preventive measures. Trial registration Clinical trials NCT00604773 (development study) and NCT00961389 (validation study).

Nursing Implementation Science: How Evidence-Based Nursing Requires Evidence-Based Implementation

PURPOSE Evidence is not always used in practice, and many examples of problematic implementation of research into practice exist. The aim of this paper is to provide an introduction and overview of current developments in implementation science and to apply these to nursing. METHODS We discuss a framework for implementation, describe common implementation determinants, and provide a rationale for choosing implementation strategies using the available evidence from nursing research and general health services research. FINDINGS Common determinants for implementation relate to knowledge, cognitions, attitudes, routines, social influence, organization, and resources. Determinants are often specific for innovation, context, and target groups. Strategies focused on individual professionals and voluntary approaches currently dominate implementation research. Strategies such as reminders, decision support, use of information and communication technology (ICT), rewards, and combined strategies are often effective in encouraging implementation of evidence and innovations. Linking determinants to theory-based strategies, however, can facilitate optimal implementation plans. CONCLUSIONS An analytical, deliberate process of clarifying implementation determinants and choosing strategies is needed to improve situations where suboptimal care exists. Use of theory and evidence from implementation science can facilitate evidence-based implementation. More research, especially in the area of nursing, is needed. This research should be focused on the effectiveness of innovative strategies directed to patients, individual professionals, teams, healthcare organizations, and finances. CLINICAL RELEVANCE Implementation of evidence-based interventions is crucial to professional nursing and the quality and safety of patient care.

Delirium in critically ill patients: Impact on long-term health-related quality of life and cognitive functioning.

Objective:To examine the impact of delirium during intensive care unit stay on long-term health-related quality of life and cognitive function in intensive care unit survivors. Design:Prospective 18-month follow-up study. Setting:Four intensive care units of a university hospital. Patients:A median of 18 months after intensive care discharge, questionnaires were sent to 1,292 intensive care survivors with (n = 272) and without (n = 1020) delirium during their intensive care stay. Measurements and Main Results:The Short Form-36v1, checklist individual strength-fatigue, and cognitive failure questionnaire were used. Covariance analysis was performed to adjust for relevant covariates. Of the 915 responders, 171 patients were delirious during their intensive care stay (median age 65 [interquartile range 58–85], Acute Physiology and Chronic Health Evaluation II score 17 [interquartile range 14–20]), and 745 patients were not (median age 65 [interquartile range 57–72], Acute Physiology and Chronic Health Evaluation II score 13 [interquartile range 10–16]). After adjusting for covariates, no differences were found between delirium and nondelirium survivors on the Short Form-36 and checklist individual strength-fatigue. However, survivors who had suffered from delirium reported that they made significantly more social blunders, and their total cognitive failure questionnaire score was significantly higher, compared to survivors who had not been delirious. Survivors of a hypoactive delirium subtype performed significantly better on the domain mental health than mixed and hyperactive delirium patients. Duration of delirium was significantly correlated to problems with memory and names. Conclusions:Intensive care survivors with delirium during their intensive care unit stay had a similar adjusted health-related quality of life evaluation, but significantly more cognitive problems than those who did not suffer from delirium, even after adjusting for relevant covariates. In addition, the duration of delirium was related to long-term cognitive problems.

Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers.

Abstract Objective: To evaluate whether risk assessment scales can be used to identify patients who are likely to get pressure ulcers. Design: Prospective cohort study. Setting: Two large hospitals in the Netherlands. Participants: 1229 patients admitted to the surgical, internal, neurological, or geriatric wards between January 1999 and June 2000. Main outcome measure: Occurrence of a pressure ulcer of grade 2 or worse while in hospital. Results: 135 patients developed pressure ulcers during four weeks after admission. The weekly incidence of patients with pressure ulcers was 6.2% (95% confidence interval 5.2% to 7.2%). The area under the receiver operating characteristic curve was 0.56 (0.51 to 0.61) for the Norton scale, 0.55 (0.49 to 0.60) for the Braden scale, and 0.61 (0.56 to 0.66) for the Waterlow scale; the areas for the subpopulation, excluding patients who received preventive measures without developing pressure ulcers and excluding surgical patients, were 0.71 (0.65 to 0.77), 0.71(0.64 to 0.78), and 0.68 (0.61 to 0.74), respectively. In this subpopulation, using the recommended cut-off points, the positive predictive value was 7.0% for the Norton, 7.8% for the Braden, and 5.3% for the Waterlow scale. Conclusion: Although risk assessment scales predict the occurrence of pressure ulcers to some extent, routine use of these scales leads to inefficient use of preventive measures. An accurate risk assessment scale based on prospectively gathered data should be developed.

Prevention and treatment of incontinence-associated dermatitis: literature review.

AIM This paper is a report of a review conducted to describe the current evidence about the prevention and treatment of incontinence-associated dermatitis and to formulate recommendations for clinical practice and research. BACKGROUND Incontinence-associated dermatitis is a common problem in patients with incontinence. It is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence. DATA SOURCES PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature, reference lists and conference proceedings were explored up to September 2008. REVIEW METHODS Publications were included if they reported research on the prevention and treatment of incontinence-associated dermatitis. As little consensus about terminology was found, a very sensitive filter was developed. Study design was not used as a selection criterion due to the explorative character of the review and the scarce literature. RESULTS Thirty-six publications, dealing with 25 different studies, were included. The implementation of a structured perineal skin care programme including skin cleansing and the use of a moisturizer is suggested. A skin protectant is recommended for patients considered at risk of incontinence-associated dermatitis development. Perineal skin cleansers are preferable to using water and soap. Skin care is suggested after each incontinence episode, particularly if faeces are present. The quality of methods in the included studies was low. CONCLUSIONS Incontinence-associated dermatitis can be prevented and healed with timely and appropriate skin cleansing and skin protection. Prevention and treatment should also focus on a proper use of incontinence containment materials. Further research is required to evaluate the efficacy and effectiveness of various interventions.

Statement of the European Pressure Ulcer Advisory Panel —pressure ulcer classification: differentiation between pressure ulcers and moisture lesions

Apressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these. The identification of pressure damage is an essential and integral part of clinical practice and pressure ulcer research. Pressure ulcer classification is a method of determining the severity of a pressure ulcer and is also used to distinguish pressure ulcers from other skin lesions. A classification system describes a series of numbered grades or stages, each determining a different degree of tissue damage. The European Pressure Ulcer Advisory Panel (EPUAP) defined 4 different pressure ulcer grades (Table 1).1 Nonblanchable erythema is a sign that pressure and shear are causing tissue damage and that preventive measures should be taken without delay to prevent the development of pressure ulcer lesions (Grade 2, 3, or 4). The diagnosis of the existence of a pressure ulcer is more difficult than one commonly assumes. There is often confusion between a pressure ulcer and a lesion that is caused by the presence of moisture, for example, because of incontinence of urine and/or feces. Differentiation between the two is clinically important, because prevention and treatment strategies differ largely and the consequences of the outcome for the patient are imminently important. This statement on pressure ulcer classification is limitedto the differentiation between pressure ulcers and moisture lesions. Obviously, there are numerous other lesions that might be misclassified as a pressure ulcer (eg, leg ulcer and diabetic foot). Experience has shown that becauseof their location, moisture lesions are the ones most often misclassified as pressure ulcers.2-3 Wound-related characteristics (causes, location, shape, depth, edges, and color), along with patient-related characteristics, are helpful to differentiate between a pressure ulcer and a moisture lesion