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ABSTRACTS
FROM THE 2ND WORLD UNION OF
WOUND HEALING SOCIETIES MEETING
Paris, 8–13 July 2004
PRESSURE ULCERS
AND NUTRITION: A NEW EUROPEAN GUIDELINE
M. Clark
Pressure ulcers are frequently associated with malnutrition; however to
what extent is this relationship valid? The European Pressure Ulcer Advisory
Panel (EPUAP) has developed a new practice guideline addressing the role
of nutrition in pressure ulcer prevention and treatment. This guideline
highlights that currently there is no strong scientific evidencefor a
direct relationship between poor nutrition and the development of pressure
ulcers, although it is possible that poor nutrition may influence the
vulnerability of tissue to extrinsic factors such as pressure. Stronger
links exist between malnutrition and the delayed healing of pressure ulcers.
The new guideline was developed by a multidisciplinary group with members
drawn from five European countries. Much of the guideline was based on
a new Cochrane review of the links between nutrition and pressure ulcers.
The draft guideline was presented during the EPUAP Annual Conference in
September 2003 and published
in draft form in the EPUAP Review with the guideline revised in light
of comments received. The final version of the guideline available in
eight European languages) covers the whole nutritional cycle and includes
weighted recommendations with regard to nutritional screening, assessment,
intervention, evaluation and followup. The guideline especially stresses
the importance of integrating nutritional activities into daily pressure
ulcer care. This presentation will discuss the development, content and
implementation of the new guideline with implementation assisted through
the development of a decision tree which can be used to aid the translation
of the guideline into locally protocols of care. The European Pressure
Ulcer Advisory Panel would like to thank Nutricia for an unrestricted
educational grant that made development of the guideline possible.
Members of the Guideline Development Group were Benati G, Clark M, Cohn
D. Jackson P, Kerry B, Langer G and Schols JMGA.
INTERRATER
AND INTRARATER RELIABILITY OF THE EPUAP PRESSURE ULCER CLASSIFICATION
SYSTEM
T. Defloor, L. Schoonhoven
Background:
Correct identification and classification of a pressure ulcer is important
for an accurate reporting of the magnitude of the problem, and for timely
prevention. The reliability of classification systems has rarely been
tested.
Aims:
To examine the interrater and intrarater reliability of classifying pressure
ulcers according to the EPUAP classification system using pressure ulcer
photographs.
Design:
Survey among nurses without special expertise in pressure ulcers.
Methods:
56 photographs of normal skin, blanchable erythema, pressure ulcers (PU)
or incontinence lesions were correctly classified by 53 PU experts. The
photographs were presented in a random order to 473 nurses. A random selection
of 9 photographs were included twice. 83 nurses did the test twice within
a time interval of one month.
Results:
The interrater reliability (k = 0.37) and the intrarater reliability (k=052)
were low. Incontinence lesions were confused most frequently with superficial
PU; 80.2% of the PU lesions (grade 2 and higher~ were identified as such.
Nurses who classified more photographs correctly, remained consistent
in their judgement. Nurses with a limited number of correct answers, frequently
changed from opinion in between two sessions.
Conclusions:
The interrater and intrarater-reliability of the EPUAP-classification
appears to be low for the assessment by nurses with no special expertise
in PU. More attention should be given to training in PU classification.
The description of the different PU grades should be further developed,
based on their clinical presentation and not only on the anatomic limits
of soft tissue damage.
OBSERVATION
OF NON-BLANCHABLE ERYTHEMA
K. Vander Wee, B. De Neve, M. Grypdonck, T. Defloor
Introduction:
The use of risk assessment scales is recommended to identify patients
at risk for pressure ulcers. For many patients however, applying these
scales results in an inefficient use of preventive measures. Recent research
has shown that waiting until non-blanchable erythema occurs before starting
prevention is a more efficient method than using the Braden scale. It
is important that non-blanchable erythema is correctly observed. The aim
of this study is to examine two methods to observe non-blanchable erythema
and to examine the interrater reliability of the observations.
Methods:
303 patients of an acute geriatric ward with erythema observed by the
researcher participated in the study. Nurses observed heels, hips and
sacrum daily. They scored the
presence of blanchable erythema or non-blanchable erythema. To distinguish
between blanchable and nonblanchable erythema, both thumb and transparent
disk were used. The researcher executed the same observations, independently.
Results:
The interrater reliability between nurse and researcher was both for the
thumb method (k = 0.67) and transparent disk (k = 0.70) substantial. The
agreement was higher for the sacrum than for the heels. The agreement
between the observations with thumb and transparent disk was high, both
at nurses (k = 0.88) and researcher (k = 0.88), however, more non-blanchable
erythema was observed with the transparent disk. The agreement was higher
for the heels, than for the sacrum.
Discussion:
The interrater reliability was higher for the sacrum than for the heels.
When using a transparent disk more non-blanchable erythema was identified.
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 or 2 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.
SEVERITY,
LOCATION, DURATION AND ORIGIN OF PRESSURE ULCER WOUNDS IN GERMANY
N. Lahmann, T. Dassen
Introduction:
Data about the severity, location, duration and origin of pressure ulcer
wounds in German Healthcare facilities are rare. Knowledge of these characteristics
could be used to evaluate the preventive and therapeutic pressure ulcer
management, i.e. long duration of pressure ulcer wounds may open the way
for a discussion about the necessity of improved or new treatment procedures.
In the years 2002 and 2003, the ‘Department of Nursing Science’
at the Humboldt-Universität zu Berlin conducted nationwide surveys
on the prevalence of pressure ulcers in German hospitals and nursing homes,
during which data about the severity, location, duration and origin of
pressure ulcer wounds were obtained. The research question is: What are
the differences of pressure ulcer wound characteristics between nursing
homes and hospitals in Germany?
Method:
The study design consisted of two point prevalence studies conducted in
April 2002 and April 2003. Specially trained ward nurses examined all
hospital patients and nursing homes residents who were able to give informed
consent. Where a pressure ulcer wound was diagnosed, the severity, origin,
duration and location had to be stated. Demographicdata and a risk assessment
according to the Braden scale were obtained. Chisquare was used to test
for statistically significant differences.
Results:
2158 out of 21,574 hospital patients and nursing home residents had a
total of 3,857 pressure ulcers. <sum> In hospitals 36.4% of these
wounds were of severity grade 2 and higher; in nursing homes the percentage
of these wounds was 46.7%. <sum> In hospitals 51.4% of all wounds
were developed nosocomially compared to 60.2% in nursing homes. <sum>
In hospitals 7.4 % of all wounds have persisted for more than three months,
29.7% in nursing homes <sum> In both types of institutions they
were mostcommonly located on the lower back area and the heels.
Summary:
In Germany pressure ulcer wounds in nursing homes are more severe, persist
longer and more often develop nosocomially in nursing homes than in hospitals.
URBAN AND RURAL USA NURSES’ KNOWLEDGE OF
PRESSURE
E.A. Ayello, FAAN, K. Zulkowski, ONS, 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 programmes. 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 analysed 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 continuingeducation programmes
for staff level nurses to enhance pressure ulcer care.
A
PHENOMENOLOGICAL STUDY TO EXPLORE THE EXPERIENCE OF LIVING WITH A PRESSURE
ULCER
C. Dealey, A. Hopkins, D. Colin, T. Defloor
Background:
Little is known of the impact of pressure ulcers on an individual’s
quality of life. This phenomenological study set out to investigate the
impact of pressure ulceration on a variety of people with different underlying
pathologies from several countries across Europe. This paper is reporting
the first stage of the study, testing the impact of having multiple data
collectors and translation from one language to another for analysis as
well as the findings from eight patients.
Methods:
Patients over the age of 65 years, with a grade 3 or 4 pressure ulcer
which had been present more than one month, were recruited to the study.
Each patient was interviewed using an unstructured format. The interviews
were taped and then transcribed. The transcriptions were sent to one person
for analysis. Standardised training was given to all those undertaking
the interviews. Following analysis the emerging themes from each interview
were examined with the interviewer to ensure validity. Transcripts that
were translated into English were verified by the interviewer for accuracy.
Results:
A total of eight patients have been recruited from four centres, three
in the UK and one in Belgium. Emerging themes from the interviews are
pain, sudden loss, restriction and equipment, Discussion of the results
will focus on the issues of validity that arise from a pan-European qualitative
study, in particular the cultural and translation influence within interview
based methodology and the reliability of the emerging themes within a
population that have multiple pathologies.
THE
EFFECT OF CLOTHING ON THE MEASUREMENT OF INTERFACE PRESSURE
J.M. Melhuish, M. Clark, R.J. Williams, K.G. Harding
Introduction:
The measurement of interface pressure between subjects and associated
support surfaces has been
exhaustively researched. The effect of clothing on these measurements
has been discussed but there is little work that has examined the effect
on measured interface pressure. It is known and we have demonstrated that
measured interface pressure is dependent on the hardness of the support
surfaces for most types of sensors.
Aim:
To examine the effect of clothing materials and associated clothing structures
(ACS) in a controlled environment on the measured interface pressure.
Method:
Synthetic mixes, Various Cotton garments and sheets were selected for
testing. Small pieces of material approximately 20 x 20 cm were cut from
each garment. Measurements were undertaken on the plain material, a 1.5
cm folded crease, seams, pockets and buttons. The materials were placed
as a sandwiched between two layers of foam (Shore “00” hardness
42) and two 10 x 10 cm metal plates. The plates were then loaded to apply
50 mmHg. Interface pressure was measured using a Tally Oxford pressure
monitor. One piece of material and its ACS’s was tested using 7
foams of increasing hardness, (shore 16–50 “000” scale),
loading 25mmHg.
Results:
The Median (Range) of the measured control interface pressure was 50 (50–50)mmHg.
Their was little effect shown on the measured interface pressures for
plain materials 50 (45–54) mmHg. Their were varying affects for
the ACS’s, not including buttons, 64.5(42–148) including buttons
68(42–310). Increasing foam hardness was associated with increasing
measured interface pressure this became more pronounced for the ACS’s.
For plain material, structures and buttons these were for foam 1 (hardness
16 “000”) 12(12–13) 13(11–16), 28(27–29)mmHg,
and for foam 7 (hardness 50 “000”) 23(23–24), 27.5(22–50),
113 (113–11 5)mmHg.
Conclusion:
Clothing has a variable effect on the measured interface pressure this
being very small for plain surfaces but
can be greatly increased over associated material structures.
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