Toshiko Kaitani

Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study

OBJECTIVE To evaluate the effectiveness and cost-effectiveness of new incentive system for pressure ulcer management, which focused on skilled nurse staffing in terms of rate of healing and medical costs. DESIGN, SETTING AND PARTICIPANTS A prospective cohort study included two types of groups: 39 institutions, which introduced the new incentive system, and 20 non-introduced groups (control). Sixty-seven patients suffering from severe pressure ulcers in the introduced group and 38 patients in the non-introduced group were included. Wound healing and medical costs were monitored weekly for three weeks by their skilled nurses in charge. MAIN OUTCOME MEASURES Healing status and related medical costs. RESULTS The introduced group showed significantly higher rate of healing compared with the control group at each weekly assessment. Multiple regression analysis revealed that the introduction of the new incentive system was independently associated with the faster healing rate (beta=3.44, P<.001). The budget impact analysis demonstrated that introducing this system could reduce cost of treating severe pressure ulcers by 1.776 billion yen per year. CONCLUSIONS The new incentive system for the management of pressure ulcers, which focused on staffing with skilled nurses can improve healing rate with reduced medical cost.

Concurrent validation and reliability of digital image analysis of granulation tissue color for clinical pressure ulcers.

Granulation tissue color is one indicator for pressure ulcer (PU) assessment. However, it entails a subjective evaluation only, and quantitative methods have not been established. We developed color indicators from digital image analysis and investigated their concurrent validity and reliability for clinical PUs. A cross‐sectional study was conducted on 47 patients with 55 full‐thickness PUs. After color calibration, a wound photograph was converted into three images representing red color: erythema index (EI), modified erythema index with additional color calibration (granulation red index [GRI]), and , which represents the artificially created red–green axis of L*a*b* color space. The mean intensity of the granulation tissue region and the percentage of pixels exceeding the optimal cutoff intensity (% intensity) were calculated. Mean GRI (ρ=0.39, p=0.007) and (ρ=0.55, p<0.001), as well as their % intensity indicators, showed positive correlations with a* measured by tristimulus colorimeter, but erythema index did not. They were correlated with hydroxyproline concentration in wound fluid, healthy granulation tissue area, and blood hemoglobin level. Intra‐ and interrater reliability of the indicator calculation using both GRI and had an intraclass correlation coefficient >0.9. GRI and from digital image analysis can quantitatively evaluate granulation tissue color of clinical PUs.

Relationship between morphological characteristics and etiology of pressure ulcers in intensive care unit patients.

PURPOSE: Pressure ulcer (PU) prevention is crucial for critically ill patients in the intensive care unit, but etiologic factors leading to their development have not yet been completely elucidated. This study explores the relationships among etiologic factors, interventional nursing care, and morphological characteristics of PUs in intensive care unit patients. DESIGN: We used a qualitative exploratory method to link morphological characteristics of specific PUs to etiologic factors. METHODS: Details of individual PUs were described by sketching the PU photograph and categorized to characterize the morphology of PUs. After identification of characteristics, the development process was evaluated by in-depth review of medical records. RESULTS: The morphological characteristics of 30 PUs were organized into 4 categories. This process revealed a type of PU not previously described, which we labeled “leaf-type.” These PUs were located on the lower sacrum, rhombic-oval in shape, and characterized by purpura and PU wrinkles. Possible etiologic factors for the specific PUs were divided into 4 categories: (1) the occurrence of PU risk episodes, (2) failure of the peripheral circulation, (3) periods of critical immobility, and (4) position change techniques inducing skin deformation. CONCLUSION: PU can be categorized into 4 morphological types, including a new category of leaf-shaped PU. We found that frequently repeated position changes such as lateral tilt and repeated head elevation caused deformation of the sacral skin that may play a role in PU development.

Predictive validity of granulation tissue color measured by digital image analysis for deep pressure ulcer healing: a multicenter prospective cohort study

This multicenter prospective cohort study examined the predictive validity of granulation tissue color evaluated by digital image analysis for deep pressure ulcer healing. Ninety-one patients with deep pressure ulcers were followed for 3 weeks. From a wound photograph taken at baseline, an image representing the granulation red index (GRI) was processed in which a redder color represented higher values. We calculated the average GRI over granulation tissue and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) and wound surface (%wound red index 80). In the receiver operating characteristics curve analysis, most GRI parameters had adequate discriminative values for both improvement of the DESIGN-R total score and wound closure. Ulcers were categorized by the obtained cutoff points of the average GRI (≤80, >80), %GRI80 (≤55, >55–80, >80%), and %wound red index 80 (≤25, >25–50, >50%). In the linear mixed model, higher classes for all GRI parameters showed significantly greater relative improvement in overall wound severity during the 3 weeks after adjustment for patient characteristics and wound locations. Assessment of granulation tissue color by digital image analysis will be useful as an objective monitoring tool for granulation tissue quality or surrogate outcomes of pressure ulcer healing.This multicenter prospective cohort study examined the predictive validity of granulation tissue color evaluated by digital image analysis for deep pressure ulcer healing. Ninety‐one patients with deep pressure ulcers were followed for 3 weeks. From a wound photograph taken at baseline, an image representing the granulation red index (GRI) was processed in which a redder color represented higher values. We calculated the average GRI over granulation tissue and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) and wound surface (%wound red index 80). In the receiver operating characteristics curve analysis, most GRI parameters had adequate discriminative values for both improvement of the DESIGN‐R total score and wound closure. Ulcers were categorized by the obtained cutoff points of the average GRI (≤80, >80), %GRI80 (≤55, >55–80, >80%), and %wound red index 80 (≤25, >25–50, >50%). In the linear mixed model, higher classes for all GRI parameters showed significantly greater relative improvement in overall wound severity during the 3 weeks after adjustment for patient characteristics and wound locations. Assessment of granulation tissue color by digital image analysis will be useful as an objective monitoring tool for granulation tissue quality or surrogate outcomes of pressure ulcer healing.

Cost–utility analysis of an advanced pressure ulcer management protocol followed by trained wound, ostomy, and continence nurses

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost‐effectiveness of the care provided using an advanced PU management protocol, from a medical providers perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1‐year time horizon to determine the incremental cost‐effectiveness ratio of advanced PU management compared with conventional care. The number of quality‐adjusted life‐years gained, and the cost in Japanese yen (¥) (

Undermining incision and healing of deep pressure ulcers: A prospective cohort study of pressure ulcers by the Japanese National Hospital Organization

US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost‐effective than conventional care.

Clinical validity of the estimated energy requirement and the average protein requirement for nutritional status change and wound healing in older patients with pressure ulcers: A multicenter prospective cohort study.

Undermining is one of the most challenging complications of deep pressure ulcers. Recommendations in most guidelines are based only on expert opinions. Here, we examined the relationship between surgical incision of the undermined space and pressure ulcer healing through a Japanese multicenter prospective cohort study. A total of 162 patients with undermining in 40 national hospitals in Japan were enrolled from July 2007 to June 2009. The incision group included 39 patients (24.1%) whose undermining was surgically incised during the observational period. Their 4‐week follow‐up data on pressure ulcer severity and areas of healthy granulation tissue were recorded as outcome variables using the DESIGN‐R pressure ulcer assessment tool. The 4‐week follow‐up was restarted after the incision in the incision group. The outcome variables over time were compared between the two groups using a linear mixed model with or without adjustment for demographic and other variables. The incision group showed more rapid improvement in the total and granulation DESIGN‐R scores compared with the nonincision group (p < 0.001 and p = 0.007, respectively, in the crude models). This study may provide the first considerable evidence to support that surgical incision of undermining may promote healing of deep pressure ulcers.

Evaluation of an advanced pressure ulcer management protocol followed by trained wound, ostomy, and continence nurses: a non-randomized controlled trial

Adequate nutritional intake is essential for pressure ulcer healing. Recently, the estimated energy requirement (30 kcal/kg) and the average protein requirement (0.95 g/kg) necessary to maintain metabolic balance have been reported. The purpose was to evaluate the clinical validity of these requirements in older hospitalized patients with pressure ulcers by assessing nutritional status and wound healing.

PATIENT RISK FACTORS FOR PRESSURE ULCERS IN THE CRITICAL CARE SETTING: 676

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Chronic Wound Care Management and Research 2015:2 39–51 Chronic Wound Care Management and Research Dovepress

Risk factors related to the development of pressure ulcers in the critical care setting

PURPOSE: Various studies have reported on patients who develop pressure ulcers within the first week or fortnight of hospitalization in the critical care setting. The purpose of this study was to identify pressure ulcer risk indicators and when the pressure ulcer occur in the critical care setting. METHODOLOGY: A prospective longitudinal study was designed to collect relevant data on all patients at risk of developing pressure ulcers. The study facility is a 606-bed tertiary care hospital. One-hundred six of the 272 subjects admitted to the ICU/HCU during 3-month period were included in this study. The criteria for selection were being: (1) an adult older than 19 years of age, (2) free from pressure ulcers on admission, and (3) hospitalized more than 24 hours. The data were collected on admission to the ICU/HCU at 48 and 72 hours after admission, and then every 48 hours until discharge, or for a maximum of 15 days. The Pearson, Chi-square, and logistic-regression analyses were used to identify the variables associated independently with pressure ulcers (SPSS ver.11.0). Informed consent was obtained. RESULTS: Subjects’ mean age was 60.0, SD 15.8 years, and mean APACHE2 score was 7.8, SD 4.3. Nineteen (7.5%) of the 272 subjects developed pressure ulcers during the study, and 8 (42.1%) of the 19 subjects developed them during surgery, which was statistically significant. (P < .004) The incidence of pressure ulcers in surgical patients in this study was 7.1%, and multivariate analysis revealed that undergoing lengthy surgical procedures, being an emergency postoperative patients, using lateral and prone position, and body mass index (BMI) were key factors. Receiver-operating characteristic (ROC) curves for BMI show best balance between sensitivity and specificity at 20.37 (75.0%, 78.1%). CONCLUSION: In the critical care setting, it is important to prevent pressure ulcer formation during surgery. Additionally, being emergency postoperative patients, lateral position, prone position, and a BMI below 20.37 were significant risk factors for pressure ulcer formation.