Pressure ulcers : predicting factors, prevention and costs

The research outline pursued with this thesis can be divided in three parts. In the first part, studies to compare the effectiveness of several interventions for the prevention of pressure ulcers were conducted. Pressure ulcer prevention focusses on the reduction of the amount and duration of pressure and shear. An alternating device intermittently removes pressure and shear from vulnerable areas. It provides pressure relief via cyclic inflating and deflating air cells. Systematic reviews and (inter)national guidelines demonstrate inconclusive results as to the superiority of one specific alternating pressure device. An example of an active support surface is an alternating pressure air mattress (APAM), available as overlays or replacement mattress, and ALPAMs (Alternating Low Pressure Air Mattresses). Differences between several types of active support surfaces can be related to differences in surface characteristics, such as cycle time, air cell inflation sequence, and pressure amplitude. The inflation and deflation of the air cells of an APAM and ALPAMs are characterized by a steep, one-stage inflation or deflation. ALPAMs were designed by the medical technology industry to generate lower pressures compared to APAMs. More recently these ALPAMs have been modified so that the transition from deflated air cell to inflated air cell is more gradual or multi-staged. As more complex technology does not necessarily lead to more effective devices, the aim of the first trial was to examine the influence of a multi-stage inflation and deflation cycle versus a one-stage inflation and deflation cycle. The multi-stage ALPAM did not result in a significantly lower pressure ulcer incidence compared to the one-stage ALPAM. Both mattresses were equally effective to prevent pressure ulcers. The time to develop a pressure ulcer was comparable in both groups. Secondly, the effectiveness of an APAM overlay was compared with the effectiveness of a one-stage and a multi-stage ALPAM. A reduced incidence of pressure ulcers was found in the multi-stage ALPAM group compared to the APAM overlay group. No significant differences in pressure ulcer development were found between a one-stage ALPAM and an APAM overlay. The median time to develop a pressure ulcer was similar among groups. Despite preventive measures provided in the effectiveness studies, a proportion of the patients developed a pressure ulcer. The identification of these ‘high risk’ patients is examined in the second part of this dissertation and is crucial to further improve the quality of care. The aim of a subsequent study was to identify factors that independently predicted the development of a pressure ulcer in an at risk population who received standardised preventive care. The presence of non-blanchable erythema, having a urogenital disorder, and higher body temperature were found to be predictive factors associated with the development of a pressure ulcer. In the third part of this thesis the cost of pressure ulcer prevention and treatment was addressed. International literature found a cost of pressure ulcer prevention per patient at risk varying between €2.65 and €87.57 per day. The cost of pressure ulcer treatment ranged from €1.73 to €812.92 per patient per day. These studies encompassed a considerable methodological heterogeneity in terms of the type of health economic design, health economic perspective, the cost components, and the health outcomes. In a subsequent study insight was provided into the cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders using a mixed perspective. In hospitals, a cost for pressure ulcer prevention of €7.88 per patient at risk per day was found. In nursing homes, a cost of €2.15 per resident at risk per day was calculated. The cost of pressure ulcer prevention for patients and residents perceived not at risk for pressure ulcer development was €1.44 per day in hospitals and €0.50 per day in nursing homes. The main cost driver was found to be the cost of labour, rather than the cost of devices. The average cost of treatment per patient per day varied from €2.34 (category I) to €77.36 (category IV) in hospitals, and from €2.42 (category I) to €16.18€ (category IV pressure ulcer) in nursing homes

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers : a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background: Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs). Objectives: Determine if silicone foam dressings in addition to standard prevention reduce PU incidence category 2 or worse compared to standard prevention alone. Methods: Multicentre, randomised controlled, medical device trial conducted in eight Belgian hospitals. At risk adult patients were centrally randomised (n=1633) to study groups based on a 1:1:1 allocation: experimental group 1 (n=542) and 2 (n=545) ‐ pooled as the treatment group ‐ and the control group (n=546). Experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on these body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU category 2 or worse at these body sites. Results: In the intention‐to‐treat population (n=1605); 4.0% of patients developed PUs category 2 or worse in the treatment group and 6.3% in the control group (RR=0.64, 95% CI 0.41 to 0.99, P=0.04). Sacral PUs were observed in 2.8% and 4.8% of the patients in the treatment group and the control group, respectively (RR=0.59, 95% CI 0.35 to 0.98, P=0.04). Heel PUs occurred in 1.4% and 1.9% of patients in the treatment and control group respectively (RR=0.76, 95% CI 0.34 to 1.68, P=0.49). Conclusions: Silicone foam dressings reduce the incidence of PUs category 2 or worse in hospitalised at‐risk patients when used in addition to standard of care. Results show a decrease for sacrum, but no statistical difference for heel/trochanter areas

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat