Ruud J.G. Halfens

Patient risk factors for pressure ulcer development: Systematic review

OBJECTIVEnTo identify risk factors independently predictive of pressure ulcer development in adult patient populations?nnnDESIGNnA systematic review of primary research was undertaken, based upon methods recommended for effectiveness questions but adapted to identify observational risk factor studies.nnnDATA SOURCESnFourteen 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.nnnREVIEW METHODSnAbstracts 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.nnnRESULTSnOf 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.nnnCONCLUSIONSnOverall 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.

A rational approach to nutritional assessment.

BACKGROUND & AIMSnConsensus regarding definitions of malnutrition and methods to assess nutritional state is lacking. We propose a definition and its operationalization.nnnMETHODSnA definition was formulated on the basis of the pathophysiology of malnutrition, while reviewing the metabolic and physiological characteristics of different populations, considered to be malnourished. The definition was operationalized to yield measures to perform nutritional assessment.nnnRESULTSnMalnutrition was defined as a subacute or chronic state of nutrition in which a combination of varying degrees of over- or undernutrition and inflammatory activity has led to a change in body composition and diminished function. Its operationalization led to four elements that may serve as the basis of nutritional assessment: (1) measurement of nutrient balance, (2) measurement of body composition, (3) measurement of inflammatory activity, and (4) measurement of muscle, immune and cognitive function. Most elements measured should be validated with gold standards; normal values should be obtained in different populations. Values obtained in people considered to be at nutritional risk should be related to outcome.nnnCONCLUSIONnA definition is proposed that reflects the pathophysiology of malnutrition and that, when operationalized, will lead to measures reflecting this pathophysiology. Such an approach may yield comparable and reproducible rates and degrees of malnutrition in populations as well as in individuals.

Validity and Reliability of Tools to Measure Muscle Mass, Strength, and Physical Performance in Community-Dwelling Older People: A Systematic Review

BACKGROUNDnThis study critically appraises the measurement properties of tools to measure muscle mass, strength, and physical performance in community-dwelling older people. This can support the selection of a valid and reliable set of tools that is feasible for future screening and identification of sarcopenia.nnnMETHODSnThe databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane were systematically searched (January 11, 2012). Studies were included if they investigated the measurement properties or feasibility, or both, of tools to measure muscle mass, strength, and physical performance in community-dwelling older people aged ≥60 years. The consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was used for quality appraisal of the studies.nnnRESULTSnSixty-two publications were deemed eligible, including tools for muscle mass (nxa0= 16), muscle strength (nxa0= 15), and physical performance (nxa0= 31). Magnetic resonance imaging, computed tomography, and a 4-compartment model were used as gold standards for muscle mass assessment. Other frequently used measures of muscle mass are dual-energy x-ray and the bioelectrical impedance (BIA); however, reliability data of the BIA are lacking. Handheld dynamometry and gait speed or a short physical performance battery provide a valid and reliable measurement of muscle strength and physical performance, respectively.nnnCONCLUSIONSnIt can be concluded that several tools are available for valid and reliable measurements of muscle mass, strength, and performance in clinical settings. For a home-setting BIA, handheld dynamometry and gait speed or a short physical performance battery are the most valid, reliable, and feasible. The combination of selected instruments and its use for the screening and identification of sarcopenia in community-dwelling older people need further evaluation.

Defining malnutrition: Mission or mission impossible?

OBJECTIVEnAlthough screening for malnutrition in health care has expanded enormously, a gold standard for the optimal definition and operationalism of malnutrition is still lacking. This report reflects expert opinions on the elements of the definition and operationalism of malnutrition and is meant to trigger further debate within the nutritional societies.nnnMETHODSnA Delphi study was performed consisting of three phases. After a literature review (phase 1), questions for a semistructured interviews (phase 2) were formulated. Subsequently, the results of these semistructured interviews were used to develop the final list of elements (for defining and operationalism of malnutrition). In phase 3 (final phase), experts were asked to provide written feedback regarding the ranking of elements concerning the importance of these elements.nnnRESULTSnTwenty-two experts (response 73.3%) were included in the final phase of this Delphi study. No overall agreement could be reached. The elements deficiencies of energy or protein and decrease in fat-free mass were most often mentioned to be particularly important in defining malnutrition. Elements mentioned to be important in operationalism of malnutrition were involuntary weight loss, body mass index, and no nutritional intake. Opinions on cutoff points regarding these elements differed strongly among experts.nnnCONCLUSIONnThis study shows that there is no full agreement among experts on the elements defining and operationalism of malnutrition. The results of this study may fuel the discussion within the nutritional societies, which will most ideally lead to an international consensus on a definition and operationalism of malnutrition.

Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria

AIMSnTo identify and describe nurses wishes, needs, knowledge and attitudes to nursing research, as well as perceived barriers to and facilitators of research utilisation in nursing practice in Austria.nnnBACKGROUNDnResearch results are not always used in daily nursing practice, despite their potential to improve nursing care quality. A variety of factors impede their implementation and use. Nurses wishes about research utilisation have scarcely been reported. No data are available yet from an Austrian perspective.nnnDESIGNnDescriptive and exploratory cross-sectional survey.nnnMETHODSnThe study was conducted in an Austrian university hospital in May 2007, including all graduate nurses (n=1825). One thousand and twenty-three nurses returned the self-reported questionnaire. Descriptive analysis was performed initially, then group comparisons (diploma <2001, ≥2001) were computed inferentially using the chi-square test.nnnRESULTSnNurses most frequently indicated wishes regarding research implementation were adequate information, structural availability and professional support. Special points of interest were topics concerning nursing phenomena and interventions. Nurses needs related to education in nursing science/research and its implementations were indicated as being predominantly of an introductory manner. Overall, nurses attitudes tended to the negative. The top three named barriers to research utilisation were lack of time (69·9%), lack of information/knowledge (45·4%) and lack of interest (25·9%). Ten statistically significant differences were found between nurses of the two compared diploma groups.nnnCONCLUSIONSnParticipating nurses perceived a lack in sufficient education/information and adequate organisational support, impeding them to use research results in daily practice.nnnRELEVANCE TO CLINICAL PRACTICEnThe results provide important insights into the matter of nurses needs regarding the use and/or implementation of research results in practice, as well as about the promotion of positive attitudes towards research and its utilisation. These findings are of special interest to nurse educators, employers and countries introducing nursing science to improve the clinical outcomes for patients.

The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes

OBJECTIVESnPressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes.nnnMETHODSnA cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake.nnnRESULTSnTwo thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%-10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes.nnnCONCLUSIONnThere is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.

The economic costs of disease related malnutrition

BACKGROUND & AIMSnDisease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands.nnnMETHODSnA cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands.nnnRESULTSnThe total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study.nnnCONCLUSIONSnThe results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable.

Psychosocial problems and needs of posttreatment patients with breast cancer and their relatives.

PURPOSEnThe study assessed and compared the psychosocial needs of patients with breast cancer and of their relatives, the patients and relatives burden of illness, anxiety, depression and distress and assessed the patients cancer treatment-related symptoms and identified relevant factors influencing patients and relatives needs.nnnMETHODnSeventy-two patients (n=72) participated with a relative in a cross-sectional mail-survey, 1-22 months after cancer treatment.nnnRESULTSnThe patients reported needing help with psychological and sexual issues. They suffered from treatment-related symptoms. More treatment-related symptoms and depression were related to the patients needs for supportive care. Their relatives needs primarily concerned access to information and communication with health care professionals. Relatives had higher levels of anxiety (25.0% vs. 22.2%), depression (12.5% vs. 8.3%) and distress (40% vs. 34%) than patients. Higher levels of depression, younger age and having a disease themselves were associated with relatives need for help.nnnCONCLUSIONnPatients and relatives substantial needs and psychological problems require professional support even after completion of the patients treatment. Continued assessment of the patients and their relatives needs and of the patients symptoms provide the basis for purposeful counselling and education. Rehabilitation programs for patients and their relatives should be developed and implemented in clinical practice.

Patient and visitor violence in the general hospital, occurrence, staff interventions and consequences: A cross-sectional survey

UNLABELLEDnAIM.: This study focuses on the experience of healthcare staff with regard to patient and visitor violence in a general hospital. The occurrence of patient and visitor violence, staffs interventions and the consequences of violence for different professions are investigated.nnnBACKGROUNDnThere is a lack of studies describing the factors influencing the occurrence of patient and visitor violence, intervention strategies and consequences. Existing studies often focus on nurses experiences and single interactive factors between staff and patients/visitors involved.nnnDESIGNnA cross-sectional survey.nnnMETHODnThe survey was conducted in 2007 including 2495 staff working on different wards in a Swiss university general hospital. The questionnaire used was the Survey of Violence Experienced by Staff German Version-Revised.nnnFINDINGSnHalf of the staff experienced patient and visitor violence in the past 12 months and 11% in the past week. The age of the staff and the length of experience in their present workplace influenced the exposure to patient and visitor violence. Violence occurred mainly when staff carried out tasks involving close personal contact. Only 16% of the staff was trained in aggression management. The feeling of confidence in managing patient and visitor violence depended significantly on the organizational attitude towards violence. The principal interventions used were calming and informative discussion.nnnCONCLUSIONnTo prevent patient and visitor violence and improve management strategies, training which focuses on communication skills, which is specific to the professional context and which emphasizes patient centeredness, need to be designed and implemented. A strong organizational commitment is imperative to reduce violence.

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

AIMS AND OBJECTIVESnThe 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.nnnBACKGROUNDnFalls are common in older people with cognitive impairment, but studies in the hospital setting are rare.nnnDESIGNnA secondary analysis of three nationwide prevalence studies in German hospitals from the years 2005, 2006 and 2007 was conducted.nnnMETHODnTrained 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnCognitively impaired older people constitute a high-risk group for accidental falls in hospitals.nnnRELEVANCE TO CLINICAL PRACTICEnFall prevention strategies in the hospital setting should address cognitively impaired inpatients as an important high-risk group.