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ABSTRACTS
FROM THE 2ND WORLD UNION OF
WOUND HEALING SOCIETIES MEETING
Paris, 8–13 July 2004
(continued)
PRESSURE ULCERS
2 (EDUCATION AND GUIDELINES) IMPROVE GUIDELINES PRESSURE ULCER CARE?
R.J.H. Halfens (NL)
Prevalence studies typically indicate that many patients have pressure
ulcers while in health care institutions. Perhaps this is because pressure
ulcer prevention and treatment is not optimal? For instance, in the Netherlands
almost 40% of pressure ulcers were not treated according to the recommendations
within the national guidelines, while only 20% of patients received appropriate
preventive measures (Bours, Halfens and Wansink, 2003). So why aren’t
guideline recommendations implemented? There are several reasons why the
production of a guideline is not always followed by changes in patient
outcome. First of all, providing new guidelines (and knowledge) doesn’t
automatically change our practice. Perhaps this is often due to the way
in which guidelines are disseminated which typically is very passive.
So to achieve the desired changes in health professionals’ behaviour
a pressure ulcer guideline may have to be actively implemented. In this
process three elements are important: the guidelines; the target group;
and the context. Starting with the guidelines: simple guidelines may be
easier to implement than more complex ones. The group for whom the guideline
is intended must have the knowledge required to understand its recommendations,
while the political, social, organisational and financial environments
must converge to make guideline acceptance and implementation possible.
We know that guidelines can change the behaviour of health professionals
and can exert a positive impact on patient outcomes, but for these positive
results to be achieved the implementation process must be effective.
PRESSURE
ULCERS 4 (RISK ASSESSMENT) A NEW (INTRINSIC) RISK FACTOR SCALE AND ITS
USEFULNESS IN JAPAN
T. Ohura (JP)
Purpose: In order to identify the risk factor for pressure
ulcers, a single nationwide case control study was carried out in Japan.
A new (intrinsic) risk factor scale (OHURA-HOTTA) is advocated as a new
assessment tool and its utility is demonstrated in detail.
Methods: New risk factors were detected from a total
of 132 pressure ulcer cases that could be followed up for three months
and then 528 control cases that also met the above demands were collected
from 125 facilities in Japan.
Results: The OH scale considers deterioration of mobility,
morbid bony prominence, edema and joint contracture as main factors with
nutrition and skin moisture as additional factors. The scale is further
classified into three levels according to the total score. It was confirmed
that the onset probability of pressure ulcers and the healing period of
pressure ulcers correlated to the levels of the scale.
Conclusion: Clinically, the OH scale was useful as a prevention and prognosis
tool for pressure ulcers. Furthermore, it may work for ‘Clinical
Path’, as it can predict the healing period and onset probability
of pressure ulcers. It can help with both mattress selection and with
estimates of the number of mattresses required by hospitals. The degree
of nursing care in each hospital can be compared with others using this
data. According to the results of a Graphical Modelling analysis, the
risk factors of the OH scale are dependent on each other. The OH screening
tool was proven to provide more predictive results than previous methods.
PRESSURE
ULCERS I (QUALITY OF LIFE) HUMAN COSTS OF PRESSURE ULCERS: REVIEW
P. Price (UK)
The development of pressure ulceration is a problem associated with a
number of concomitant conditions and a range of symptoms, and although
little research has been completed on the impact on everyday life, there
is an understandable assumption that it profoundly affects health-related
quality of life. Qualitative work has shown that the impact of pressure
ulcers is wide ranging, with physical social and financial aspects affected,
whilst changes in body
image and the loss of independence I control are profound (e.g., Langemo
et al 2000). Studies that have used validated health-related quality of
life tools (e.g., Clark 2002, Franks et al 2002) have used the Short-Form-36
in conjunction with tests of physical function (such as the Bartel). Franks
et al (2002) have shown that whilst there is a negative impact on health-related
quality of life for patients with pressure ulceration, this is similar
to other patients treated within the community setting with other conditions.
Clark (2002), reporting on a cohort of 2,507 patients, has highlighted
the difficulties of using generic self-report tools with this patient
population. There are a number of challenges that professionals in this
area need to consider, for example, as a condition specific tool for pressure
ulceration is not available to use alongside generic tools, then it is
difficult to assess the impact of new treatments in terms of the direct
impact on the patient. Many patients in this group will not be able to
complete a self-report of impact on health-related quality of life, which
raises the issue of the use of proxy ratings for some patients. In addition
to reviewing the current literature, this presentation will raise questions
of methodology and ethics that related to this important topic.
EVALUATION
TOOLS DESIGN: A NEW EVALUATION METHOD FOR PRESSURE ULCERS
H. Sanada (JP)
Background: The Japanese Society of Pressure Ulcers identified
the need for treatment guidelines to assess pressure ulcer severity and
to monitor the healing process. The society’s academic committee
developed a pressure ulcer severity classification and healing progression
monitoring tool to fulfil this need. DESIGN is an acronym derived from
the six items used to classify and assess wound-healing progress: Depth,
Exudate, Size, Infection, Granulation, Necrosis. P is added to the acronym
when a pocket (undermining) is present.
Objective: This study reviews the validity and reliability of
DESIGN, a tool for classifying pressure severity and monitoring progression
towards healing. Only the tool’s healing progression component was
evaluated.
Method: Inter-rater reliability was evaluated by calculating
the agreement rate of scores, based on eight photos of pressure ulcers
and six actual ulcers, made by a panel of seven nurses. Validity was assessed,
using the same eight photos, by comparing DESIGN scores with those made
using the validated Pressure Sore Status Tool (PSST).
Results: The DESIGN inter-rater reliability results showed a
high correlation of r = 0.98 for the photos and r = 0.91 for the real-life
patients with pressure ulcers, respectively, for all raters based on total
scores. For validity, a correlation greater than 0.91 was found between
the DESIGN and PSST scores.
Conclusion: Based on our results, DESIGN was found to
have both high inter-rater reliability and high validity among theseven
nurses who quantitatively evaluated the wound-healing progress of the
pressure ulcers in this study.
Inquiry
into the Use of Anti-Pressure Ulcer Supports in a Geriatric Service
T. Jacquet, S. Haulon, V Gautler, F Bloch, G. Abitbol.
Introduction: For some years certain geriatric services profit
from dynamic anti-pressure ulcer supports. Is this type of
material correctly used? What type of patients benefit from such supports?
Methods: In a geriatric service in Paris the Pressure Ulcer Unit
has been active for six years. The inquiry was carried out on a given
day. The supports present on the beds and armchairs, the demographic characteristics
of the patients, their level of dependence, their GIR score and Norton
score were noted.
Results: 156 patients were present on that day, average
age 88 ±8 years. 109 (70%) of the patients had the benefit of a
static-type bed support, 39 (25%) had a dynamic type support (continuous
pressurised air or alternating air) and 8 (55) were on a hotel-type mattress.
16 (10%) of patients had a pressure ulcer. 87% of all supports taken together
were properly installed, 85% of the dynamic supports and 94% of the static
supports. 63 (40%) of the patients were installed on comfortable armchairs
or adapted chairs. The patients who had a dynamic support had a greater
number of pressure ulcers (31% vs. 3.7%; p<0.001), a lower GIR score
(1.6 vs. 2.6; p<0.0001), a lower Norton score (9.8 vs.13.7 p<0.0001)
and were less continent (8% vs. 40%; p<0.001). Significantly more of
the patients with a dynamic support were installed in comfortable or adapted
armchairs (p<0.05) and were installed in rooms with rails on the ceiling
(p<0.001). The appraisal of the suitability of a support in relation
to the patient showed there was no difference with respect to the type
of support, nor was there any difference as regards age, sex or type of
hospitalisation.
Discussion: More than 85% of supports were properly installed,
the patients who had a dynamic type of support were more dependent and
had more pressure ulcers. The selection
of the Pressure Ulcer Unit to distinguish the two principal types of support,
and the two target populations, those
already having a pressure ulcer or at very high risk and those at risk,
seemed to be effective overall, the use of the risk
scale and GIR permitting to position the patients suitably on a support.
Occlusive
Moist Environment for Early Stage Pressure Ulcers with Necrosis
K. Tsukaoa, K. Tokunaga, M. Nagano
Treatment of early stage pressure ulcers with necrotic tissue is controversial.
This study evaluates using occlusive moist environment and retrospectively
determining the safety.
Methods: 64 uninfected necrosic ulcers, not for selected
surgical debridement, from 59 patients from a 3.5 year period were included.
Initial assessments were Stage II or III.
Results: After an average of 15 days, the ulcers were
re-assessed as 13 Stage II, 50 Stage III, and one Stage IV. Hydrocolloid
dressings were used for 48 ulcers, of which 13 Stage II ulcers, 29 Stage
III ulcers, and one Stage IV ulcer had begun epithelization. Necrosis
of three Stage III ulcers became hard eschars and two ulcers were infected.
Hydrogell or lysozyme hydrochloride cream was used for seven Stage III
ulcers that had started epithelization. Silver sulfadiazine cream was
used for eight Stage III ulcers, of which six had started epithelization,
one remained unchanged, and one necrosis became hard eschar.
Conclusions: Occlusive moist environments, especially
using hydrocolloid dressings, are useful and safe for the early stage
uninfected pressure ulcers with necrosis. After providing autolysis of
necrosis, surgical debridement should be selected.
Paediatric
Scalp Pressure Sores-Aetiology and Prevention Measures
BA De Souza, A. Ghattaura, M Shisu
Introduction: Paediatric multi-trauma patients with head injury
are susceptible to occipital pressure sores. The incidence of pressures
sores amongst paediatric patients is not well documented but there is
evidence that children do get pressure sores. In the paediatric intensive
care there is an assessment tool available and should be used to identify
patients at risk. The consequence of this is scarring alopecia which requires
surgery and has significant morbidity.
Patients: six patients sustained scalp pressure injury with age
ranges from 2–10 years. The factors most strongly associated with
pressure injury were nutritional status, mobility and conscious level.
Other factors were systemic infection, coagulation disturbance, neuromuscular
blockade and vasopressor treatment.
Conclusions: To prevent pressure injury occurring it
is essential to
identify those potentially at risk. Risk assessment scores will assist
in the identification of patients likely to develop pressure sores.
Pressure
Ulcer Prevalence in Nursing Homes – Comparison of the Netherlands
and Germany
A. Tannen, T Dassen Gerrie Sours, R. Halfens
Introduction: The prevalence of pressure ulcers (PU) among care
dependent people is still underreported in national health care statistics.
That is why there is a need for epidemiological research. In addition
to the prevalence of PU within health care facilities a comparison with
other countries also provides sufficient information for judging the
extent and severity of the subject. Since 2000, the abovementioned departments
have been conducting annual prevalence studies in the Netherlands and
in Germany and have discovered repeatable differences between the two
nations. The aim of this analysis is to describe and explore the differences
between and similarities of the two countries regarding nursing home residents.
Method: All in-care residents of the participating nursing
homes, who handed in their informed consent, were examined by trained
nurses of the respective facilities. For each of the residents a standardised
questionnaire was completed and details about risk of PU according to
the Braden scale, nursing interventions and characteristics of available
PU were recorded. The samples consisted of 77 Dutch facilities with 8250
residents and 15 German facilities with 1276 residents.
Results:
With regard to the demography of those two groups the same average age
(82–84 years) and share of sex (74– 82% female) were established.
Concerning the risk of PU the two samples showed the same average Braden
score (17.39–17.88) and a similar share of risk patients (64.7–
65%). Hardly any differences were discovered in individual Braden items.
The prevalence (when referring to the risk patients) was 38.3% in the
Netherlands and 16.8% in Germany. Considerable correlation was found between
PU prevalence and the residents’ age.
Summary: The residents of both samples bear resemblance
concerning the individual risk factors (such as age and Braden score).
Additionally, the share of risk patients is equal in both study populations.
Therefore, it is worthy of note that the prevalence of PU among nursing
home residents in the Netherlands is different from the one in Germany.
Further comparisons of nursing prevention interventions and supply quality
will have to be drawn in future.
Pressure
Ulcer Prevalence: Using European Methodology in the Irish Health Care
Setting
J. O’Brien, Z. Moore
Background: Pressure ulcers are common, however, in Ireland
there are no national prevalence figures available and no national guidelines
exist for pressure ulcer prevention and management.
Aims:
1. To gain insight into the use of the EPUAP pressure ulcer minimum data
set
2. To establish pressure ulcer prevalence and risk status of the population
in an acute hospital setting.
3. To identify the number and severity of pressure ulcers and prevention
strategies in use.
Methods: A survey was conducted using the EPUAP pressure
ulcer minimum data set. Permission to conduct the study was granted from
the Director of Nursing Services and ethical principles were adhered to.
The study site was chosen using random sampling and all patients were
assessed (n = 519). Data analysis was carried out utilising SPSS version
11
Results: Pressure ulcer prevalence was 15%. Most patients
were in the acute care/high dependency care setting (63%) and 20% were
at risk of pressure ulcer development ranging from low-high (Braden Scale).
78 pressure ulcers were identified and 57(73%) were grade 1 or2 damage
(EPUAP grading). A range of prevention measures was used, the appropriateness
of these varied among the risk groups.
Discussion and Conclusion: This study provides a clearer
understanding of the scale, nature and severity of the problem of pressure
ulceration. Based on this information plans can be drawn regarding appropriate
resource allocation and future research within the Irish population.
Pressure
Ulcers: Recommendations Associated with Prevention
P Brocker, F Mignolet, MJ Darmon, F Berthier, G. Daideri
The objectives of this study were to carry out an audit for an inquiry
into the prevalence of pressure ulcers in the whole of our University
Hospital Centre and to develop the knowledge and practices of staff as
well as the implementing the coordinated and appropriate use of the various
existing medical devices and supports. The enquiry was carried out on
a given day after the training of the investigators in the use of the
Braden scale and the description of pressure ulcers according to the classification
of Garches. It was completed by an audit of the resources. The results
concern all the 1611 in-patients (784 men and 827 women). 268 patients
(16.6%) presented one or more pressure ulcers, but only 146 (9.1%) did
so if the S1 stage (simple redness) was excluded. The prevalence determined
was 7.5% (n = 120) and 3.7% (n = 60) if S1 was excluded. The most significant
prevalence was found among the highest age ranges (35.6% for those over
85 years), and 77.3% of the total number of pressure ulcers was found
among the population over 65 years. The prevalence of pressure ulcers
by activity group was highest in the follow-up care and Rehabilitation,
then in the Intensive Care Unit, with Long-term care, Medicine and Surgery
following. The most frequent location of ulcers was the heel (46%), followed
by the sacrum (26%). The S1 stage represented 70% of the pressure ulcers,
S2 17% and S3 9%. This inquiry also revealed a failure in rehabilitation
methods for the prevention of pressure ulcers due to lack of appropriate
use of supports and the lack of information and training of the medical
and nursing staff.
Urban
and Rural USA Nurses’ Knowledge of Pressure Ulcers
E.A. Ayello, Faan, K. Zulkowski, DNS, RN, CWS
Introduction: Pressure ulcers continue to be an important issue
for nursing home residents in the United States. Documentations and treatment
of pressure ulcers are critical components in the provision of optimal
care, in this population. In long term care (LTC) facilities, it is the
staff nurses that must understand how to assess risk for pressure ulcers
that have developed, and implement prevention/ treatment programs. The
knowledge level of nurses employed in long term care facilities has not
been examined. Nurses in rural areas may have fewer opportunities for
continuing education programmes than their urban counterparts. It is not
known if there is a difference in pressure ulcer knowledge by geographic
location.
Methods: Nurses employed in LTC both urban
and rural settings have been invited to participate in the study by completing
a standardized pressure ulcer knowledge tool developed by Pieper and a
demographic sheet developed by the authors.
Results: Data is being analyzed using SPSS 11.5 statistical software.
Data collection is in progress with over 700 surveys mailed. The presentation
will give the results of both urban and rural nurses’ knowledge
of pressure ulcer identification, risk and treatment using a standardized
pressure ulcer tool developed by Pieper.
Discussion: These data will help in planning future continuing
education programmes for staff level nurses to enhance pressure ulcer
care.
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