Maria Grypdonck

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.

Qualitative Health Research in the Era of Evidence-Based Practice

Evidence-based health care (EBHC) sets the tone in health care and health care research nowadays. Qualitative health researchers have to position themselves in a world that is dominated by it. The popularity of EBHC is not due to the rationality of its tenets. In this article, the author addresses major problems in EBHC. Qualitative research is important for providing the understanding that is necessary to apply findings from quantitative research properly and safely. Basic studies about the human experience in illness and regarding human behavior and meaning in general remain of great value, even in the era of EBHC. Qualitative research also plays an important role in developing scholarship.

A review of why patients with leg ulcers do not adhere to treatment

AIM To provide an overview of what is known thus far about reasons for and determinants of non-adherent behaviour. BACKGROUND Compression, leg exercises and leg elevation are regarded as essential components in leg ulcer treatment and in the prevention of ulcer recurrence. Non-adherence to leg ulcer regimen is a major problem. Reasons for non-adherence are not fully understood. DESIGN Systematic review. METHOD Medline, CINAHL and the Cochrane database were explored from 1995 - December 2007. Reference lists of retrieved articles were searched. Studies were eligible if they included patients with venous or mixed leg ulcers, reported reasons or determinants of non-adherence and were published in English, Dutch, French or German. Thirty-one studies were included. RESULTS Non-adherence is a multidimensional problem. Pain, discomfort and lack of valid lifestyle advice by healthcare professionals were primary reasons for non-adherence from patients perspective. CONCLUSIONS Healthcare professionals mainly focus on patient-related factors such as poor motivation, lack of knowledge and understanding and unwillingness. The beliefs that compression was unnecessary, uncomfortable, worthwhile and prevented recurrence significantly determined (non-)adherence. RELEVANCE TO NURSING AND NURSING SCIENCE: Interventions to promote adherence will require a multifaceted approach and a holistic comprehensive assessment. Therapeutic non-judgemental relationships are essential to enhance patient adherence. Effective pain management is recommended and social support by family or significant others could be encouraged. Healthcare professionals should give clear, unambiguous and tailored information. Research can best focus on the factors and processes affecting patient adherence to leg ulcer treatment. Comprehensive adherence-enhancing strategies could be developed and their effectiveness should be tested.

Prediction of pressure ulcer development in hospitalized patients: a tool for risk assessment

Objectives: To identify independent predictors for development of pressure ulcers in hospitalized patients and to develop a simple prediction rule for pressure ulcer development. Design: The Prevention and Pressure Ulcer Risk Score Evaluation (prePURSE) study is a prospective cohort study in which patients are followed up once a week until pressure ulcer occurrence, discharge from hospital, or length of stay over 12 weeks. Data were collected between January 1999 and June 2000. Setting: Two large hospitals in the Netherlands. Participants: Adult patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days were eligible. A consecutive sample of 1536 patients was visited, 1431 (93%) of whom agreed to participate. Complete follow up data were available for 1229 (80%) patients. Main outcome measures: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital. Results: Independent predictors of pressure ulcers were age, weight at admission, abnormal appearance of the skin, friction and shear, and planned surgery in coming week. The area under the curve of the final prediction rule was 0.70 after bootstrapping. At a cut off score of 20, 42% of the patient weeks were identified as at risk for pressure ulcer development, thus correctly identifying 70% of the patient weeks in which a pressure ulcer occurred. Conclusion: A simple clinical prediction rule based on five patient characteristics may help to identify patients at increased risk for pressure ulcer development and in need of preventive measures.

Sitting posture and prevention of pressure ulcers.

The aim of this study was to gain insight about the influence of body posture on the pressure at the seat surface and to establish to what extent different seat cushions designed for incontinent patients reduce maximum pressures. Pressures were measured for 56 healthy volunteers in eight postures using four cushions. The posture in which the lowest maximum pressure was measured was the sitting-back posture with the lower legs on a rest. If the seat could not be tilted back, the maximum pressure in the upright sitting posture with the feet on the ground was significantly lower than sitting upright with the legs supported on a rest. Sliding down and slouching caused the highest maximum pressure. Regular checking of the posture and using positioning cushions should form part of any pressure-ulcer prevention protocol. The four selected cushions each have different pressure-reducing effects. A thick air cushion (Repose) has the lowest maximum pressure and is significantly better than the other cushions at reducing the high pressure when slouching or sliding down.

Do pressure relief cushions really relieve pressure

In a laboratory setting, interface pressures of 29 cushions and a sheepskin were measured on 20 healthy volunteers. Each participant was seated in an upright posture with their back against the back of the chair, hands resting on the lap, knees bent at an angle of 90 degrees, and feet resting on the floor. Only 13 cushions had any pressure-reducing effect. Gel cushions and sheepskins appear to have no pressure-reducing effect. The category of foam includes both cushions that reduce interface pressure very well and cushions that increase interface pressure. The lowest interface pressures were measured on air cushions and on some foam cushions.

Neurodevelopmental treatment after stroke: a comparative study

Background: Neurodevelopmental treatment (NDT) is a rehabilitation approach increasingly used in the care of stroke patients, although no evidence has been provided for its efficacy. Objective: To investigate the effects of NDT on the functional status and quality of life (QoL) of patients with stroke during one year after stroke onset. Methods: 324 consecutive patients with stroke from 12 Dutch hospitals were included in a prospective, non-randomised, parallel group study. In the experimental group (n = 223), nurses and physiotherapists from six neurological wards used the NDT approach, while conventional treatment was used in six control wards (n = 101). Functional status was assessed by the Barthel index. Primary outcome was “poor outcome”, defined as Barthel index <12 or death after one year. QoL was assessed with the 30 item version of the sickness impact profile (SA-SIP30) and the visual analogue scale. Results: At 12 months, 59 patients (27%) in the NDT group and 24 (24%) in the non-NDT group had poor outcome (corresponding adjusted odds ratio = 1.7 (95% confidence interval, 0.8 to 3.5)). At discharge the adjusted odds ratio was 0.8 (0.4 to 1.5) and after six months it was 1.6 (0.8 to 3.2). Adjusted mean differences in the two QoL measures showed no significant differences between the study groups at six or 12 months after stroke onset. Conclusions: The NDT approach was not found effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of this approach.

How evidence-based is venous leg ulcer care ? A survey in community settings.

AIM This paper is a report of a study to describe venous leg ulcer care regarding compression, pain management and lifestyle advice in community settings and to identify factors that predict the provision of lifestyle advice by nurses. BACKGROUND Incongruence between evidence and practice in leg ulcer care has been reported. Little is known about predictive factors related to the provision of lifestyle advice. METHOD Two focus interviews and a Delphi procedure were used to develop a self-administered questionnaire based on the Graham questionnaire. Nurses employed by community healthcare organizations and independent nurses in private practices participated (n = 789). The data were collected in 2006. FINDINGS Compression was applied in 58.7% of patients with venous ulcers. Pain was present in 82.9%. A third of patients with pain received analgesics, but half of these patients (52.1%) took analgesics as prescribed. Half of the nurses (50.8%) gave lifestyle advice related to the leg ulcer. It was mainly instructions about leg elevation (68.3%), promoting physical activity (39.8%) and optimizing nutrition (16.7%) that were provided. Nurses who perceived themselves to have adequate leg ulcer knowledge and skills were 3.75 times more likely to provide lifestyle advice compared with those lacking such knowledge and skills. Nurses who found leg ulcer care not rewarding, rarely successful or difficult gave statistically significantly less lifestyle advice than those who found it rather rewarding, successful and not difficult. CONCLUSION Patients with leg ulcers receive less than optimum care and patient education. A particular challenge lies in leg ulcer education programmes and pain management.

Researching lived experience in health care: Significance for care ethics

The aim of this article is to demonstrate the usefulness of qualitative research for studying the ethics of care, bringing to light the lived experience of health care recipients, together with the importance of methods that allow reconstruction of the processes underlying this lived experience. Lived experiences of families being approached for organ donation, parents facing the imminent death of their child and patients being treated using stem cell transplantation are used to illustrate how ethical principles are differentiated, modified or contradicted by the narrative context of persons concerned. The integration of empirical data into ethics will help caregivers in their ethical decision making and may enrich care ethics as a narrative and interpretative field.

Multi-stage versus single-stage inflation and deflation cycle for alternating low pressure air mattresses to prevent pressure ulcers in hospitalised patients: A randomised-controlled clinical trial

INTRODUCTION The duration and the amount of pressure and shear must be reduced in order to minimize the risk of pressure ulcer development. Alternating low pressure air mattresses with multi-stage inflation and deflation cycle of the air cells have been developed to relieve pressure by sequentially inflating and deflating the air cells. Evidence about the effectiveness of this type of mattress in clinical practice is lacking. AIM This study aimed to compare the effectiveness of an alternating low pressure air mattress that has a standard single-stage inflation and deflation cycle of the air cells with an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. METHODS AND MATERIALS A randomised controlled trial was performed in a convenience sample of 25 wards in five hospitals in Belgium. In total, 610 patients were included and randomly assigned to the experimental group (n=298) or the control group (n=312). In the experimental group, patients were allocated to an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. In the control group, patients were allocated to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. The outcome was defined as cumulative pressure ulcer incidence (Grade II-IV). An intention-to-treat analysis was performed. RESULTS There was no significant difference in cumulative pressure ulcer incidence (Grade II-IV) between both groups (Exp.=5.7%, Contr.=5.8%, p=0.97). When patients developed a pressure ulcer, the median time was 5.0 days in the experimental group (IQR=3.0-8.5) and 8.0 days in the control group (IQR=3.0-8.5) (Mann-Whitney U-test=113, p=0.182). The probability to remain pressure ulcer free during the observation period in this trial did not differ significantly between the experimental group and the control group (log-rank χ(2)=0.013, df=1, p=0.911). CONCLUSION An alternating low pressure air mattress with multi-stage inflation and deflation of the air cells does not result in a significantly lower pressure ulcer incidence compared to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. Both alternating mattress types are equally effective to prevent pressure ulcer development.