PRESSURE ULCERS: BACK TO BASICS – THE FUNDAMENTAL PRINCIPLES
Eighth EPUAP Open Meeting, Aberdeen Conference Centre, Scotland, 5–7 May 2005
Selected Abstracts

EVIDENCE IN PRESSURE ULCERS
Ruud J. G. Halfens, PhD, FEANS
Universiteit Maastricht, Department of Health Care Studies,
Section Nursing Science. r.halfens@zw.unimaas.nl

Evidence can not be seen as separate from the evidence based practice movement. Evidence based practice or medicine
can be defined as: ‘the conscientious, explicit, and judicious use of current best evidence about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett et al, 2000). Other authors include also the patient’s preferences into the definition of evidence based practice. This presentation will be limited to the best available external clinical evidence’ with respect to the prevention of pressure ulcers. Without trying to be complete, a short overview will be given of the evidence regarding the prevention of pressure ulcers: what do we know about the causes of pressure ulcers, what do we know about the risk factors and what do we know about preventive methods.

Next, the question will be raised what we need to know. This question will be answered not only from a scientific viewpoint but also from a clinical viewpoint. The ultimate goal of future knowledge must be reducing the incidence of pressure ulcers. Based on some general rules, suggestions will be made for future research.

THE IMPACT OF A TOPICAL AGENT (Corpitolinol 60) IN PRESSURE ULCER PREVENTION IN ELDERLY HOSPITALISED PATIENTS (GIPPS STUDY)
Barrois B.1, Meaume S.2, Colin D.3, Bohbot S.4 and Allaert F.A.5.
(1) CHG Gonesse, Mans. (2) Hôpital Charles Foix, Ivry.
(3) Centre de l’Arche, Le Mans. (4) Laboratoires Urgo.
(5) Dept of Epidemiology, McGill University, Canada /
Cenbiotech, University Hospital, Dijon.

Introduction
Pressure ulcers are problematic both by their human aspects (morbidity-mortality, self-image, quality of life) and their medical-economic repercussions. If a consensus has today been reached to prevent pressure ulcer development, the advantage of using superficial gentle massage with topicals on high-risk areas, remains controversial in the absence of evidence.

Patients and Methods
To evaluate the interest of a superficial gentle massage on high risk areas, an observational prospective trial was conducted in France in 36 hospital geriatric departments that observed the French National Recommendations for pressure ulcer prevention.

The 36 centres included patients who presented a high risk of developing a pressure ulcer (physician’s clinical evaluation / geriatric validated risk scale): an 8 weeks’ follow-up period was undertaken and the patients were examined on a weekly basis. In association with a global preventive treatment, 40.4% of the patients do not receive any superficial gentle massage, conducted in 34.5% of the patients with corpitolinol 60 and with other topicals in 25.1% of the cases. The effects of using a topical agents were evaluated by a logistic regression analysis using as co-factors the elements previously identified by the univariate analysis as likely to impact on the development of a pressure ulcer.

Results
The study involved 1121 patients aged 84.7 ± 8.1 years. At the end of the two-month follow-up period, this population showed a pressure ulcer incidence of 15.7%, regardless of location. This incidence is significantly higher in patients presenting a mixed incontinence or a very high risk of pressure ulcer.

The logistic regression analysis showed for the sacrum that only the use of Corpitolinol 60 significantly reduced the incidence of pressure ulcers (p = 0.04), with an odds ratio (relative risk) indicating that the number of new pressure ulcers was reduced by practically a half.

Summary
The results of this first observational study conducted in the prevention of pressure ulcers show that a superficial gentle massage of the sacral area with a Corpitolinol 60- based topical should be included in pressure ulcer prevention protocols for the elderly.

A STUDY TO INVESTIGATE THE KNOWLEDGE AND UPTAKE OF AN INTEGRATED CARE PATHWAY (ICP), FOR THE PREVENTION AND MANAGEMENT OF PRESSURE ULCERS IN ELDERLY PATIENTS WITH A HIP FRACTURE
Elaine Bethell1 and Sue Bale2
(1) Sandwell and West Birmingham Hospitals NHS Trust,
(2) Gwent Healthcare NHS Trust.

Introduction
This study investigates the knowledge and uptake of an Integrated Care Pathway (ICP), for the prevention and management of pressure ulcers in elderly patients with a hip fracture.

Aims
To explore the patient experience, investigate nurses’ knowledge, and the extent to which the ICP has been implemented into clinical practice.

Method
A case study approach, where a ‘case’ comprised a patient with a fractured neck of femur and those nurses caring for that patient. Data collected were triangulated and the following data collection methods were used:
• Patient records
• Direct observations of patient care
• Skin assessment of bony prominences
• Patient interviews
• Nurses questionnaires

Ten consecutive patients who had experienced fractured hips were invited to and participated in this study. Seventyseven nurses that cared for them also participated.

Results
Five main themes emerged from the data: patient partnerships, patients’ remembering, documentation and the potential for litigation, nurses’ busyness and nurses’ recognition of knowledge deficits. These themes will be discussed in light of what is already known from prior research and how this study contributes to knowledge in this area. The value of triangulation that is integral in case study design has been realised. This was especially noted with regard to the themes of patients remembering and documentation and the potential for litigation.

Summary
The results of this study support the findings of researchers and legal experts that also highlight the problems related
to lack of documentation (Tingle, 1997; Moody, 2001; Dimond, 2002; Taylor 2003). If direct observations of care had not been included in this study design then the results would have led the researcher and others to believe that the ICP had not been followed, whereas analysis of the different sources of data that were triangulated revealed that it had.

A number of recommendations are made for local Trust activity and for the wider research community. These include:
• Developing a more user friendly ICP for patients and staff
• Involving patients in ICP development
• Devising a strategy for informing patients about their care using a novel idea and review of the equipment step down policy

References
Dimond B. (2002) Legal Aspects of Nursing. Longman, Essex.
Moody M. (2001) Why nurses end up in court. Nursing Times. 97: 8 24–26.
Taylor H. (2003) An exploration of the factors that affect nurses’ record keeping. British J of Nursing, 12: 12, 751–758.
Tingle J. (1997) pressure sores: counting the legal cost of nursing neglect. British J of Nursing. 6: 13, 757–758.

PATIENT AND FAMILY EDUCATION FOR PRESSURE ULCER PREVENTION IN BELGIAN HOME CARE
Paquay L1,3, Verstraete S1, Vanderwee K2, Defloor T2, Buntinx F3,4 , Debaillie R1 and Geys L1.
(1) Wit-Gele Kruis van Vlaanderen, Belgium.
(2) Dept of Nursing Science, Universiteit Gent, Belgium.
(3) Dept of General Practice, Katholieke Universiteit Leuven, Belgium.
(4) Dept of General Practice, Universiteit Maastricht, The Netherlands

Introduction
There were two reasons for the implementation of a patient and family education program in the ‘Wit-Gele Kruis’, a large organisation for home care nursing in Flanders, Belgium.

Firstly, in a previous study we conducted, it was found that the Belgian Guidelines for Prevention of Decubitus
Ulcers (BGPDU) were incompletely followed. Secondly, it is clear that because of the limited presence of a nurse in the patient’s home, family caregivers have major responsibilities in pressure ulcer prevention. The aim of this study is to evaluate the implementation of a patient and family education program for pressure ulcer prevention.

Methods
From September 2004 through February 2005 the teaching protocol was designed and pilot tested by a multidisciplinary expert panel. The content of the teaching protocol was based on the 2004 updated BGPDU. Starting in March 2005, the protocol will gradually be implemented throughout the ‘Wit-Gele Kruis’, an organisation employing 4,600 home care nurses in 110 regional departments.

Firstly, one referent nurse per regional department will be trained in the updated BGPDU and in strategies for approaching informal caregivers. In a second step, the referent nurse will inform and educate her colleagues of the regional department. Finally, all primary nurses will provide education to patients and their family caregivers using an information leaflet.

In order to support the nurses in their educational efforts, an instructive booklet and a short schematic work procedure were developed. The implementation will be evaluated by means of a prevalence study without control group in a representative sample of the patient population.

Outcome measure is the prevalence of effective and ineffective measures for pressure ulcer prevention before and six months after the implementation program. BGPDU will be used as the referent standard to evaluate the effectiveness of the applied preventive measures.

Expected results
A significantly higher prevalence of effective measures and a reduction of ineffective measures are expected.

THE EPUAP PRESSURE ULCER PREVALENCE SURVEY – A COMPARISON BETWEEN DATA COLLECTED IN 2002 AND 2004
Lena Gunningberg RN, PhD1,2
(1) Dept of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden.
(2) Nursing Research and Development, Surgery Division, University Hospital, Uppsala, Sweden

Introduction
In 2001/2002, the European Pressure Ulcer Advisory Panel (EPUAP) conducted a prevalence survey of pressure ulcers across a range of hospitals located within five European countries. Each patient was visited by two registered nurses; a data collector and a staff nurse. The patient’s skin was carefully inspected and any pressure ulcer was classified according to the EPUAP grading system. The Braden scale and the incontinence item from the Norton scale were used to calculate the patient’s risk for pressure ulcer development. Prevention in bed and chair was registered. In Sweden, a detailed analysis of the data collected in the university hospital (n = 612) was conducted. Departments with the highest prevalence rates were surgical/orthopaedic, medical and geriatric departments. Preventive strategies were surprisingly lacking. These results have been presented at different levels at the hospital, education has been conducted and guidelines for purchase of pressure reducing devices have been developed.

Aim
The aim of this study was to repeat the EPUAP pressure ulcer prevalence survey and compare the results with data collected two years ago.

Methods
The population consisted of all patients, 18 years and older, admitted to the hospital ward before midnight the day of the survey. All inpatients areas in the surgical/orthopaedic, medical and geriatric departments were surveyed. A total of 369 patients were included (89.3% of eligible patients). The survey was performed on 23 March 2004, following the methodology develop by EPUAP.

Results
There were no significant differences in gender, age or Braden score between the patient groups surveyed in 2002 and 2004. The prevalence of pressure ulcers in 2002/2004 were in surgical/orthopaedic care 26.8%/17.3%, in medical care 23.6%/26.7% and in geriatric care 59.3%/50.0%. There was a tendency to a reduced prevalence of pressure ulcers in the surgical/orthopaedic departments (p = 0.051). The use of preventive strategies had increased.

Conclusion
Pressure ulcer has now been established as a quality indicator on hospital level and results on pressure ulcer prevalence and prevention should be reported annually by all departments. The EPUAP methodology has facilitated this development.

A NEONATAL AND PEDIATRIC EVIDENCELINKED PRESSURE ULCER AND SKIN CARE PERFORMANCE IMPROVEMENT INITIATIVE
Mona Baharestani, PhD, ANP, CWOCN, CWS, FAPWCA,
Long Island Jewish Medical Center, New Hyde Park, NY.
Rosanne Vertichio, MS, RN, Mary Beth Higgins, BSN, RN,
Mark Kurot, MSN, NNP and Betty May, BSN, RNC,
Schneiders Children’s Hospital, New Hyde Park, NY.

Introduction
There is a dearth of literature specifically addressing pressure ulcers in the neonatal and pediatric populations. Yet, similar to adults, acutely ill and immobilized neonates and children are at high risk for pressure ulcers. In fact, pressure ulcer incidence rates as high as 27% have been reported among critically ill infants and children, with most occurring within two days of admission.1 Significant variation among non-critical hospitalized pediatric patients has been cited in the literature with regards to prevalence (0.47–13%) and incidence (0.29–7%). Skin breakdown such as skin tears, intravenous extravasations and diaper dermatis is estimated to affect approximately 15% of hospitalized infants.2 Alterations in thetissue integrity of this acutely ill population can result in increased pain, risk of infection, mortality,
cost, length of stay and litigation. In response to the occurrence of pressure ulcers on the shoulders, chin and chest of patients in the prone position with Acute Respiratory Distress Syndrome (ARDS) in the Pediatric Intensive Care Unit (PICU), septal ulcers among neonates with nasal prong continuous positive airway pressure (CPAP) and occipital ulcers in those receiving High Frequency Oscillatory Ventilation (HFOV) in the Neonatal Intensive Care Unit (NICU) a pressure ulcer and skin care performance improvement initiative committee was formed at the Schneider Children’s Hospital.

Purpose
To describe the development of a comprehensive neonatal and pediatric evidence-linked pressure ulcer and skin care programme.

Methods
A multi-specialty Neonatal and Pediatric Skin Care Performance Improvement Committee composed of the Director
of Wound Healing, Assistant Administrators of Nursing from Adolescence and the NICU and Nurse Managers of PICU
and NICU was formed. Committee goals were to strategically examine the incidence of pressure ulcers and skin
breakdown as quality measures and to develop a corrective action plan. Identification of the need for standardized, evidence-linked prevention and treatment guidelines; valid and reliable risk assessment and skin condition tools; tabulation of epidemiological data; a standardized product formulary and development of monitoring tools spawned an
extensive review of the literature and a Prevalence and Incidence collaborative with Hill-Rom. A systematic review of
MEDLINE, PubMed, the Cochrane Database and the search engine Google was performed using the search terms ‘pressure ulcer’, ‘decubitus ulcer’, and ‘skin care’. The search terms were combined with ‘pediatric’, ‘neonatal’, and ‘risk assessment’. The search was limited to articles published after 1994. Hand searches were also performed from the bibliographies of selected articles. Using Hill-Rom Prevalence Survey Scantron Forms a pre-guideline Prevalence and Incidence study was performed and results were compared to benchmarks and interim PICU post-guideline implementation
data.

Results
Complete skin and risk assessments were performed on 123 hospitalized neonatal and pediatric patients, followed
by chart reviews. Thirteen patients were found to have pressure ulcers (prevalence 10.6%) and all were facility acquired. Forty-five percent of pressure ulcers were on the head (occipital–15%, septal–15% and ear–15%) and 31% on the hand. Seventy percent of ulcers were partial-thickness (41%–Stage I, 29%–Stage II), 12%–Stage IV and 18%– Unstage-able/Necrotic. All thirteen patients were critically ill PICU or NICU patients with high risk scores. Pressure ulcer prevalence was 23% (nine out of 39 patients) in the NICU and 20% (four patients out of 20) in the PICU. No ulcers were identified among non-critical care hospitalized patients. Documentation pertaining to pressure ulcer prevention and ulcer status was scored as adequate in only 12% of cases. After implementation of the standardized pressure ulcer and skin care programme which includes daily risk scoring, prevention and treatment guidelines, product formulary, staff education, incidence tracking and acquisition of positioning devices and support surfaces, the interim analysis of the PICU revealed a three-fold decrease in the pressure ulcer incidence (5.8% vs. 20%) and 100% adequate documentation of risk status, skin status and guideline implementation from admission throughout the hospital stay. A repeated hospital-wide prevalence and incidence study will be performed in one month, coupled with continuous monthly incidence tracking.

Discussion
Implementation of a neonatal and pediatric evidence-linked standardized skin care and pressure ulcer prevention and
treatment programme has resulted in daily age appropriate pressure ulcer risk and neonatal skin condition scoring,
more accurate documentation of skin breakdown and pressure ulcer staging, appropriate consultation, increased
staff knowledge and improved patient outcomes. In the PICU a 3-fold decrease in pressure ulcer incidence was
found (one terminally ill patient developed a Stage II pressure ulcer out of a total of seventeen critical patients). 100%
of patient’s medical records demonstrated appropriately documented risk scoring, skin assessment and guideline implementation.

Conclusion
Interim-results in the PICU post-implementation of an evidence- linked skin and pressure ulcer prevention and treatment program demonstrate positive patient outcomes (decreased pressure ulcer incidence, appropriate guideline implementation and complete documentation by nursing staff). A hospital-wide audit will be performed in one month,
coupled with continuous monthly incidence tracking in order to analyze the effectiveness of the programme within
the entire Schneider Children’s Hospital.

References
1. Curley, M.A.Q., et al. Predicting pressure ulcer risk in pediatric patients – the Braden Q, Nursing Research 52(1): 22–31, January/February 2003.
2. Mc Lane, K.M., et al. The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey – a multi-site study, JWOCN 31(4): 168–178, July/ August 2004.

AN EVALUATION OF HYPER-OXYGENATED FATTY ACID ESTERS (Sanyrene®) IN THE PREVENTION OF PRESSURE ULCERS
D. Colin1, D. Chomard2 and J.L. Saumet3
(1) Medical Director– Rehabilitation Hospital, Centre de l’Arche, Le Mans, France.
(2) Rehabilitation Centre, Le Bignon du Maine, France.
(3) Head of Laboratory for Vascular Investigations, University Hospital, Angers, France.

Introduction
Prevention of pressure ulcers is a priority for nursing staff. Although the means employed to ensure prevention are well known, these are not always evaluated in a rigorous manner.

Methods
We performed a study using transcutaneous oxygen pressure (TcPo2) measurements to evaluate the efficacy of a
solution containing hyperoxygenated fatty acid esters (Sanyrène®) proposed in the prevention of stage 1 pressure
sores. Sacral TcPo2 was measured before and after Sanyrène® application in 28 patients presenting a risk of pressure sore development.

Results
Mean TcPo2 values were :
• 57.2 ± 12.2 mmHg before pressure exertion without Sanyrène® (R1),
• 48 ± 14.3 mmHg during pressure exertion without Sanyrène® (A1),
• 58.5 ± 10.4 mmHg before pressure exertion with Sanyrène® (R2),
• 53.7 ± 16.4 mmHg during pressure exertion with Sanyrène® (A2).

Statistical analysis showed that there was a significant difference between the TcPo2 values during the pressure exertion phase before and after Sanyrène® application (A1 / A2 – p = 0,014). Oxygen pressure values decreased significantly when the patient applied pressure to the sacral region before Sanyrène® was applied (R1 / A1 – p = 0.012) whereas no difference was noted after Sanyrène® application (R2 / A2 – p = 0.5). Sanyrène® therefore decreases the negative effects of pressure exertion on skin microcirculation in the sacral region.

Summary
These results should be confirmed by further studies in an attempt to describe more precisely the mechanisms of action
involved and the effects of Sanyrène® on skin microcirculation and, by consequence, its role in pressure ulcer prevention.

HOW TO PREVENT PATIENTS WITH A HIP FRACTURE FROM DEVELOPING PRESSURE ULCERS
Ami Hommel1,3, Kerstin Ulander2, Karl-Göran Thorngren3
(1) Department of Nursing, Lund University, Sweden.
(2) Department of Health Sciences, Kristianstad University, Sweden.
(3) Department of Orthopaedics, Lund University
Hospital, Sweden.

Introduction
Patients with hip fractures are increasing in numbers in Sweden as well as in the rest of the world due to an ageing population. Patients with a hip fracture are old and often suffer from concomitant diseases and therefore are prone to be affected by complications such as pneumonia, urinary tract infection and pressure ulcers. If a patient develops a pressure ulcer at the heel he/she might not be able to get up and walk which leads to further complications. At the University Hospital in Lund, Sweden, 480 patients with a hip fracture were consecutively included in a prospective study between 01/04/2003 and 31/03/2004. Preliminary results concerning the first 200 patients in the control group and last 200 patients in the intervention group will be presented.

Method
We used a quasi randomized design. When a patient with a suspected hip fracture arrived to the Acute and Emergency Unit (A & E) the study nurses where called to test the patient for lucidity with Short Portable Mental Status Questionnaire. Not lucid patients were included after permission from their relatives. To find patients at risk of developing pressure ulcers we used the Braden Scale for both groups and also the Modified Norton Scale for the intervention group. All patients at risk were placed on pressure relief mattresses. We classified all pressure ulcers according to the European pressure Ulcer Advisory Panel’s classification.

Patients were observed from the arrival to hospital until discharge, and followed up after four and twelve months. The intervention started after six months and consisted of; three litres of oxygen/minute preoperatively and the first days postoperatively, more sufficient intravenous pain relief at the A & E and more frequently already in the ambulance,
intravenous supplementation before and after surgery and a special nutritional drink twice a day postoperatively.
Routines were changed so the patient did not have to return to the A & E after X-ray; instead they were transported
directly to the Orthopaedic ward. All pressure relief was highlighted, such as alternating pressure mattresses.
Furthermore the patients were given a higher priority in the waiting list for surgery.

Results
The male/female ratio was in the control group 30/70% and in the intervention group 35/65%. Mean age was in the control group 81.5 years (SD 10.5) and 80.1 years (SD 10.4) in the intervention group. Sixty-eight percent of the patients in the control group and 66% in the intervention group arrived directly from their homes, patients already at hospital were 5% versus 3%, and the rest of the patients came from different accommodations for the elderly. In the control group 39% of the patients were not lucid at admission to hospital versus 35.5% in the intervention group. Patients that already at admission had a pressure ulcer at the buttock were 3% versus 2%. Pressure ulcer at heels was 1% in both groups. There were no patients with pressure ulcer on other places in the control group; while it was 0.5% in the intervention group. At discharge 15% versus 7.5% of the patients had a pressure ulcer at buttock. Six percent versus 3% of the patients had a pressure ulcer at heels and 3% versus 2.5% suffered from a pressure ulcer at other places. None of the patients in the intervention
group had a pressure ulcer after four months. The results at 12 months of follow up are still under collection and will
be presented at the conference.

Summary
The results indicate the importance of the intervention since the development of pressure ulcer was reduced by 50% at discharge and at follow up after four months.

CLINICAL EVALUATION OF THE EFFECTIVENESS OF A MULTIMODAL STATIC PRESSURE RELIEVING DEVICE
J. Osterbrink1,2, H. Mayer2 and Gerhard Schröder3
(1) Florida International University, Miami, USA.
(2) Institut für Pflegewissenschaft, Private Universität Witten/Herdecke, Stockumer Strasse 12, 58453 Witten, Germany. (3) GSK Kommunikation, Uslar-Sohlingen.

Introduction
The aim of the study was to provide proof of the effectiveness of a support aid for the prevention or treatment of pressure sores. The system under review was REPOSE, a range of air-filled polyurethane products comprising a mattress overlay, a cushion, foot protectors and a wedge.

Methods
The study was conducted according to a randomised, comparative and explorative design. The ethical approval was given by the ethical committee by the University of Witten- Herdecke. All patients were supported either by the REPOSE system or by small or large-celled alternate pressure systems.

All available patients in one hospital and residents of eight nursing homes who met the inclusion criteria (pressure sore minimum grade 2, geriatric patients, or those with neurological illness or patients undergoing operations) were randomly allocated to the included products for a total period of nine months. Measurement, realised by an standardised protocol which considered preventive and therapeutic aspects of the measured systems, occurred over a maximum of 28 days per subject. The main parameters were: general wound healing, weekly changes in wounds, wound healing success according to support system.

Results
Fifty patients were included in the study. The study showed a clear superiority (p = 0.009) of REPOSE compared to the small-cell support systems regarding of the wound healing tendency as well as the healing period. REPOSE were in those parameters comparable to the large-cell systems (p = 0.212) in this study group. Patients were significantly more satisfied with the REPOSE system than patients who were cared for using the comparative systems (p < 0.001 smallcell system and p = 0.024 large-cell system).

Conclusion
REPOSE provides a highly effective system that can be used in multimodal fashion for both preventative and therapeutic purposes within the study group. Evidence was presented that patients with wounds in the classically exposed body points at risk of pressure sores who were supported on the REPOSE system showed an improved tendency to heal.