Nils Lahmann

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The groups main findings are summarised in this paper.

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.

Falls in older hospital inpatients and the effect of cognitive impairment: a secondary analysis of prevalence studies

AIMS AND OBJECTIVES The objective of this study was to compare fall rates in older hospital inpatients with and without cognitive impairment. Relationships between age, gender, mobility, cognitive impairment, care dependency, urinary incontinence and medical disciplines were investigated. BACKGROUND Falls are common in older people with cognitive impairment, but studies in the hospital setting are rare. DESIGN A secondary analysis of three nationwide prevalence studies in German hospitals from the years 2005, 2006 and 2007 was conducted. METHOD Trained staff nurses used a standardised instrument to collect data about accidental falls within the last two weeks in their institutions and about other patient characteristics. Data from 9246 patients aged 65 years or older from 37 hospitals were analysed. RESULTS The fall rate for cognitively impaired patients was 12·9%, while only 4·2% of older persons without cognitive impairment experienced a fall. Comparison between medical disciplines showed great differences concerning fall risk for confused and non-confused inpatients. In multivariate logistic regression analysis, the odds-ratio association of cognitive impairment and falls was 2·1 (CI 1·7-2·7). Higher age (OR 1·5, CI 1·2-1·9), greater care dependency (OR 1·6, CI 1·1-2·1), reduced mobility (OR 2·6, CI 1·9-3·7) and being a patient on a geriatric ward (OR 1·8, CI 1·1-2·9) were also statistically significant predictors in this model. CONCLUSIONS Cognitively impaired older people constitute a high-risk group for accidental falls in hospitals. RELEVANCE TO CLINICAL PRACTICE Fall prevention strategies in the hospital setting should address cognitively impaired inpatients as an important high-risk group.

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.

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.

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.

Prevalence of deep tissue injuries in hospitals and nursing homes: Two cross-sectional studies

BACKGROUND Deep tissue injuries are severe damages underneath the intact skin caused by long-endured, unrelieved pressure or shear forces. Empirical evidence regarding the magnitude of this health problem is limited. OBJECTIVE Investigation of the prevalence, characteristics of persons affected and identification of the most affected body locations. DESIGN Two cross-sectional studies in 2008 and 2009. SETTINGS Nursing homes and hospitals throughout Germany. PARTICIPANTS 6919 (year 2008) and 8451 (year 2009) hospital patients and nursing home residents. METHODS Trained nurses conducted full skin assessments and collected demographic data based on written data collection forms. The Braden scale was used to measure pressure ulcer risk. RESULTS Pressure ulcer prevalence including grades 1-4 and deep tissue injuries ranged from 4.3% (95% CI 3.8-4.9) in nursing homes to 7.1% (95% CI 6.2-8.0) in hospitals. Point prevalence rates of deep tissue injuries were 0.4% (95% CI 0.2-0.5) in hospitals and less than 0.1% in nursing homes. In total, 30 persons were affected by 38 deep tissue injuries. The mean age was 73.4 and the mean Braden scale sum score was 12.8. The most frequently affected anatomic sites were heels (n=24) and ischial tuberosities (n=6). CONCLUSIONS Nurses must be aware that deep tissue injuries exist in clinical practice. Deep tissue injuries seem to be more common in hospitals than in nursing homes and heels are more prone to this kind of injuries than other body sites. Whenever such a lesion is suspected, optimal pressure relief is required to enable the affected tissue to heal.

Skin care practice in German nursing homes: a German-wide cross-sectional study

Due to anatomical and physiological changes in the course of aging and due to increased vulnerability, there are special skin care needs in elderly and care‐dependent persons. Little is known about skin care practice in German long‐term care facilities. The aim of the study was to gather epidemiological data about skin care practice in German nursing homes.

Pressure ulcer prevalence rates from 2002 to 2008 in German long-term care facilities.

Background and aims: Pressure ulcers continue to be an important issue in long-term care facilities. Besides quality initiatives (implementation of guidelines) and increased public awareness of the problem, little is known about the actual extent of the problem in Germany. The aim of this study is to provide information on the magnitude of this problem and to show whether there have been any changes through the years 2002 to 2008. In addition we wanted to know if the results were representative. Methods: 18,706 residents in 218 long-term care facilities (response rate 77.5%). Skin examination of each resident by qualified trained nurses after informed consent was given by resident or proxy. Application of Chi-square tests, chi-square trend tests and one-way ANOVA to assess differences and trends across the years. Comparisons of study samples with data characterizing the potential population. Results: Regarding gender, age, and pressure ulcer risk, the yearly samples were comparable. Pressure ulcer prevalence rates decreased from 12.5% (year 2002) to 5.0% (year 2008) (p<0.001). Prevalence rates, excluding non-blanchable erythema, decreased from 6.6% (year 2002) to 3.5% (year 2008) (p<0.001). Conclusions: Pressure ulcer prevalence in German long-term care facilities decreased from 2002 to 2008. It is highly probable that this decrease was due to more effective strategies and better prevention.

Impact of prevention structures and processes on pressure ulcer prevalence in nursing homes and acute‐care hospitals

AIM The study aimed to give a description analysis of pressure ulcer-related structures, processes and outcomes in nursing homes and acute-care hospitals that participated once, twice and thrice in prevalence surveys. DESIGN Repeated nationwide, multicentre, cross sectional surveys have been conducted. METHODS A total of 7377 residents in 60 nursing homes and 28,102 patients in 82 acute-care hospitals in Germany participated in annual point prevalence surveys. Because of their strong differences in sampling and in order to be able to display the differences occurring during the repeated (first, second and third) participation of the institutions, they were arranged according to their frequency and order of participation. The percentage of used guidelines and risk assessment scales (structures), prevention devices and measures (processes), and prevalence and nosocomial prevalence (outcomes) among all persons at risk was calculated. RESULTS The samples within the arranged groups showed no clinically relevant demographical differences. Nosocomial prevalence rates in hospitals dropped from 26.3% in the first year to 11.3% in the last year (nursing homes from 13.7% to 6.4%). The use of pressure ulcer-related structures remarkably increased during each repetition to more than 90%. Regarding the use of preventive measures and devices as an indicator for pressure ulcer-related processes results were more incoherent. CONCLUSION Repeated participation in pressure ulcer surveys led to a decrease in outcomes (lower pressure ulcer prevalence rates), to high opposite effects regarding pressure ulcer-related structures (increased use of all guidelines/risk assessment scales) and to moderate adverse effects regarding pressure ulcer-related processes (increased use of most preventive measures and devices).