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ABSTRACTS
FROM THE 2ND WORLD UNION OF
WOUND HEALING SOCIETIES MEETING
Paris, 8–13 July 2004
(continued)
PRESSURE ULCERS
I (QUALITY OF LIFE) THE NEXT STEP: USING LARGE DATABASES TO MEASURE QUALITY
OF CARE
D. Berlowitz (US)
Information on pressure ulcer status is increasingly available from large
databases and is often considered for use when assessing the quality of
care. In the United States, current initiatives are using data on pressure
ulcers from a variety of settings including nursing homes, home care,
and acute care hospitals. A basic understanding of the strengths and weaknesses
of these data are essential if one is to develop a comprehensive understanding
of the quality of care. Among the issues are the reliability of the data;
whether the data provides an accurate description of the quality of care;
how best to inform providers and consumers on performance; and optimal
means to using these data in assessing and improving care.
PRESSURE
ULCERS 2 (EDUCATION AND GUIDELINES) QUALITY CF NATIONAL AND INTERNATIONAL
GUIDELINES: A REVIEW
M. Clark (GB)
Many national and international guidelines have been produced that seek
to assist pressure ulcer prevention and management. While there is considerable
convergence between guidelines with recommendations offered primarily
on the basis of expert opinion there has been no attempt to compare the
quality of different guidelines. Until recently the lack of comparisons
of guideline quality may have stemmed from there being no accepted audit
tool with which guideline development and content could be assessed.
The release of the AGREE instrument (www.agreecollaboration.org)
in 2001 provides an approach allowing the quality of clinical guidelines
to be assessed. This presentation will report the process and results
of a comparison of three pressure ulcer guidelines (developed by the European
Pressure Ulcer Advisory Panel, the US Agency for Health Care Policy &
Research and the UK National Institute for Clinical Excellence where each
guideline was assessed by minimum of four reviewers.
PRESSURE
ULCERS 3 (SUPPORT SURFACE EFFECTIVENESS) CLINICAL EVALUATION OF SUPPORT
SURFACES: A REVIEW
N. Cullum (UK)
A systematic review has been undertaken in order to establish the relative
effectiveness of different pressure-relieving support surfaces in reducing
the development of new pressure ulcers. Studies in any language, published
or unpublished, in which participants were randomised, and which reported
the incidence of new pressure ulcers as an outcome were eligible for inclusion.
After a comprehensive search for studies, study selection and data extraction
were undertaken by one reviewer and checked by a second. Individual study
validity was appraised by two reviewers independently. 41 eligible RCTs
were identified. The validity of eligible studies was variable with only
half providing sufficient information for us to judge that allocation
to support surfaces was truly random. Blinded outcome assessment was used
in 10 studies. Median sample size in individual studies was 80 (range
12 1166). Foam alternatives to the standard hospital foam mattress reduce
the incidence of pressure ulcers in people at risk of developing pressure
ulcers. The relative merits of alternating and constant low pressure devices,
and of the different alternating pressure devices for pressure ulcer prevention
are unclear. These and other findings will be presented alongside an overview
of the validity of trials in this area, and the methodological challenges
associated with the evaluation of support surfaces.
PRESSURE
ULCERS 3 (SUPPORT SURFACE EFFECTIVENESS) MAINTAINING APPROPRIATE SKIN
MOISTURE AND TEMPERATURE OF THE PATIENT: A BIOMEDICAL ENGINEERING OVERVIEW
E. Flam, L.I. Raab (US)
Excess moisture and over-heating weaken the skin. Excess moisture also
increases friction and shear leading to greater damage from these forces.
The skin of a patient can be more resistant to developing pressure ulcers
if conditions that weaken it are controlled. The area of the patient’s
skin in contact with the support surface is most susceptible to these
adverse conditions. Low Air Loss therapy (LAL) is considered as a valuable
means to help control these conditions. In effective LAL therapy, air
flow from the cushions of the support surface removes the excess moisture
and heat. From a Biomedical Engineering perspective, the design of an
LAL system must take the following factors into account: the sources of
excess moisture and temperature; the quantity of excess moisture produced;
the elevation of the skin temperature; the air flow available for managing
these excesses; and the ability of the support surface to effectively
use the air flow to remove the excess moisture and heat. In this symposium
section, the determination of these factors is detailed. An example is
then provided to demonstrate how their interaction can result in an effective
clinical outcome.
PRESSURE
ULCERS 4 (RISK ASSESSMENT) DO RISK ASSESSMENT TOOLS WORK?
B. Barrois (FR)
Pressure ulcers occur on elderly and reduced mobility patients. Many studies
choose pertinent risk factors and asses
their validity. Using a validate tool is necessary. No strategy as allowed
pressure ulcer abolition. Fiability No study is randomised. BRADEN scale
is the most studied. It can be used for children in USI (Curley). It must
be associated with understanding the clinical uses (Russel) and repeated
(Pokorny) WATERLOW scale is specific for very old patients. NORTON scale
is more specific than Waterlow for elderly. Limits BRADEN scale Cut-off
s difficult to determine. Waters). Predictive factors are: very old woman,
with cognitive and mobility reduction (Horn) WATERLOW scale Anthony showed
than age is predictive but gender is not, without scientific proof for
validity to each item. Four items: continence; skin aspect; mobility;
and ability to transfers are valid. (Papanikolaou) NORTON scale Over evaluation
appear in 64%. In palliative units, activity, mobility and age are predictive
(Henoch) Specific factors appear for children (Samaniego) and smokers.
For elderly using medics and institution entry (Baumgarten) are predictive
indicators. Pain reduces motility and increase the risk (Reddy). Confusion,
hypo albuminémia and bowel incontinence are significant (Reed).
New tools OASIS asses risk level.
Conclusion:
Using an assessment tool for risk factors is useful. It is better than
clinical feeling but it is improved by clinical assessment.
Every scale as good sensitivity and poor specificity. The new idea from
2000 is assessment of predictive factors. No tool is actually very efficient.
PRESSURE
ULCERS 4 (RISK ASSESSMENT) WHAT ARE RISK FACTORS: SENSE OR NONSENSE OF
PRESSURE ULCER RISK ASSESSMENT SCALES
T. Defloor (BE)
Risk assessment scales are considered to be essential tools for providing
pressure ulcer prevention care. There is a wide consensus that prevention
plans should include mechanisms for predicting which patients are more
likely to develop
pressure ulcers and that interventions should be directed to the vulnerable.
Risk assessment tools are used to help identifying those patient who are
at risk. In 1962 the first pressure ulcer risk assessment scale—the
Norton scale— was designed and tested. Since the 1980’s several
new risk assessment scales have been developed (Braden, Waterlow, Knoll,
CBO, etc.). The currently available risk assessment scales are only of
limited value. It may be expected that many patients are falsely identified
as at risk or not at risk. Sensitivity and specificity are commonly used
to evaluate the validity of risk assessment scales. The use of intermediate
preventive measures decreases the risk of pressure ulcers development
and means that sensitivity and specificity criteria are not the most appropriate
method to validate risk
assessment scales. An analysis of published studies on risk assessment
scales reveals that although some patients got preventive measures and
others did not, this was not taken into account. Consequently, generalisation
of those results is not possible. Rethinking risk assessment scales and
research on pressure ulcer incidence using risk assessment scales in combination
with a preventive protocol is needed.
PRESSURE
ULCERS 6 (THERAPY DEVICES) MODE OF ACTION
D. Berlowitz (US)
The healing of a pressure ulcer is a complex process that frequently requires
months of Intensive therapy. Reducing the time required to heal a pressure
ulcer, and the cost of care, are important goals. A wide variety of adjunctive
interventions are available that may promote the healing of pressure ulcers.
These therapy devices include electrical stimulation, negative pressure
wound therapy, noncontact normothermic wound therapy, ultrasound, ultraviolet
radiation, and hyperbaric oxygen. Each of these therapy devices has been
hypothesized to have a unique mode of action that will be reviewed. Evidence
supporting the efficacy of these interventions will also be considered.
PRESSURE
ULCERS 5 (SURGICAL REPAIR) SURGICAL TREATMENT OF PRESSURE SORES
C. Kauer (FR)
For the plastic surgeon, the pressure treatment needs two actions: resection
and reconstruction. We exclude also all pressure sores where the medical
treatment with adapted dressing and nursing allows a directed healing
The surgical treatment concerns the pressure sores with a minimal height
of 5cm for the diameter, located in area with bone protrusion, essentially
pressure sores of the pelvic arch. The surgical treatment requires three
stages:
1) preparation stage with information of the patient for the surgical
imperatives;
2) surgery stage with the choice of a secure technique which needs to
preserve the maximum of skin and muscle, useful in case of recurrence;
3) post-operative stage requiring cooperation and responsibility of the
patient. The techniques are multiple from the most simple such as local
plasty, to the most sophisticated such as distal flaps cutaneous, muscular,
or mainly musculo cutaneous. An imperative condition: thick tissue cover,
well vascularised, occasionally sensitive, overall bringing a durable
mattress on the bone protrusion area. The indications are directed by
two factors: the patient and the pressure sore. Four elements linked to
the patient, supervise the choice of the ideal indication: cooperation;
autonomy; nutritional balance; continence or controlled incontinence.
Depending on the location of the pressure sore, four rules guide the choice
of the technique used: one operative stage, direct closure of the donor
site, respect of the cutaneous and muscular capital of each possible location
of the pressure sore, most reduce delay of hospitalisation.
Conclusion:
It exists an ethic of the surgery treatment of pressure sores: the surgeon
has a commitment by the choice of adapted techniques and an obligation
of result with the target to give function the most rapidly possible to
the patient with pressure sores.
Key-words:
Pelvics, Musculo-cutaneous flaps, Autonomy.
PRESSURE
ULCERS 5 (SURGICAL REPAIR) PREVENTION OF RECURRENCE AFTER SURGERY
M.J. Lubbers (NL)
A patient who needs surgical repair for a pressure ulcer, is always at
risk of recurrence after surgery. In general, the condition of this patient
is impaired. The circulation and sensibility at the top of the surgical
repair is less than normal. This patient always needs quality pressure
ulcer after care. The problem is the fragmented health care system. Prevention
of pressure ulcers needs a holistic approach. To improve the level of
care in one place and to disregard the others is useless. Most use of
high-tech devices is in specialist centres or IOU settings. In the after
care after surgery, often less advanced beds, mattresses and cushions
are used. Therefore, the recurrence rate is high. Only with a total holistic
approach is this kind of surgery effective.
PRESSURE
ULCERS 6 (THERAPY DEVICES) DEVELOPING TRIALS
J. Nixon (UK)
Clinical trials which aim to compare the effectiveness of pressureulcer
prevention and treatment therapy devices present a number of challenges
relating to both trial design and trial conduct, such as the definition
and measurement of endpoints and complex patient populations and care
environments which impact upon trial participation, outcome assessment
and compliance. Both problems and solutions will be discussed and presented
including: a brief overview of: superiority, equivalence, non-inferiority
and sequential trial designs; the importance of quality components such
as an a priori sample size, allocation concealment, intentionto- treat
analyses and interpretation of results in minimizing bias and; the use
of Good
Clinical Practice guidelines and the CONSORT statement as quality frameworks
for the planning
and conduct of clinical trials in the field.
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