Pressure Ulcers as a Commonly Encountered Health Care Problem - Literature review Example

Pressure sore management in adult patients Introduction: Pressure sores, which have also been termed as bed sores, pressure ulcers and decubitus ulcers, are a common health care problem encountered especially in the geriatric population and hospitalised patients. The term pressure ulcer has been defined by the European Pressure Ulcer Advisory Panel as ‘an area of localised damage to the skin and underlying tissue’ [Jos061]. Pressure ulcers can develop solely from or due to a complex interplay of several different factors including and not limited to extrinsic factors such as pressure, shear forces and friction; and certain intrinsic factors or patient factors, such increased age, poor nutritional status, the presence of comorbid conditions or physical disability. The prevalence of pressure ulcers varies, depending on the population being studied, the health care setting under consideration and the assessment tools used to measure outcomes. In the United Kingdom, the prevalence for pressure ulcers ranging between 10% to 33% has been reported[Pre94]. Pressure ulcers are a serious concern for all health care providers since they not only cause significant morbidity and impair quality of life amongst patients, but also pose an economic burden on the health care system by escalating health care costs associated with an extended period of hospitalisation and additional treatment costs, including costs of providing intensive nursing care and specialised equipment[Pre94]. During the year 2008, the annual cost for the management of pressure ulcers in the United Kingdom was found to approximately £1.4-2.1 billion, amounting to almost 4% of the total NHS expenditure[Bes08]. Grading of Pressure Ulcers: Pressure ulcers are graded according to the European Pressure Ulcer Advisory Panel (EPUAP) guidelines and have been classified into four different grades based on their severity. Grade I pressure ulcers have been defined as a localised area of non blanchable erythema limited to the skin with both the skin and the underlying tissues being intact. Grade II pressure sores refer to a superficial ulcer with the damage extending into the dermis and sometimes extending beyond the dermis to involve the epidermis. Grade III ulcers include ulcers causing full thickness skin damage, extending into the subcutaneous but not involving the fascia. Grade IV ulcers are the most severe and involve all layers of the skin and the damage extending to the muscle and bone[Eur10]. Management Strategies: The management of pressure ulcers is complex and demands attention to several aspects of patient care. The treatment of pressure ulcers involves the use of topical agents and dressings. The use of agents which promote an environment conducive to healing such as hydrocolloids, hydrogels, hydrofibres, foams, films, alginates and soft silicones for dressing has been advocated in literature[Bes08]. The use of antibiotics and other topical or systemic antimicrobial agents in the treatment of pressure ulcers is not supported by literature. Another effective strategy in the treatment of pressure ulcers, especially those of higher grade is wound debridement. For Grade III and IV ulcers, sometimes surgery maybe required inorder to debride the wound and to cover the defect with a flap if needed[Bes08]. Most of the management of pressure ulcers focuses on prevention of pressures ulcers from developing and to prevent progression once ulcers have developed. Since pressure is a key factor in the aetiology of pressure sores, most preventive strategies focus on and aim to relieve pressure. These include the use of pressure relieving support surfaces and frequent repositioning of the patients[Bes08]. Several pressure reducing support devices have been introduced recently, which include static devices such as mattress overlays, and dynamic devices which include dynamic mattresses, air-fluidized mattresses, and dynamic overlays[Jos061]. Similarly, frequent mobilization and encouraging activity amongst patients are other effective strategies for minimizing pressure. Till date, there has been no consensus regarding the optimal frequency for repositioning in patients with pressure ulcers. However, the current standard of care is 4 hourly repositioning on a pressure reducing mattress and 2 hourly repositioning without a pressure reducing mattress[Def05]. As discussed above, poor nutritional status is one important risk factor for the development of pressure ulcers. It is thus postulated that nutritional rehabilitation of the patient is an important parameter in the management of pressure ulcers. However, the evidence in this regard is inconclusive till date[Bes08]. In the recent era of technology and advancement, several novel therapeutic strategies have been proposed in the management of pressure ulcers. These include the application of negative topical pressure to facilitate healing, the use of therapeutic ultrasound and electrotherapy and electromagnetic therapy[Bes08]. However, the data regarding the efficacy of these treatment modalities is still scarce and further research is required to unveil the role of these modalities in pressure ulcer management. Importance of this topic to nursing: The management of pressure ulcers requires a multidisciplinary approach. Nurses play a pivotal role in the provision of effective management and preventive strategies for pressure ulcers. The management of pressure ulcers resides predominantly in the hands of the nurses especially in elder care institutions and hospices were nurses deliver most of the care. As discussed below, the management of pressure ulcers is based predominantly on preventive strategies aimed at alleviating pressure and other factors involved in the causation of pressure ulcers. These preventive strategies are usually delivered by the nurses and thus knowledge regarding the identification, management and prevention of pressure ulcers is of prime importance for the nurses. Critical Appraisal of studies: This section critically appraises two studies regarding pressure ulcer development, viz. ‘Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions’ and ‘An Assessment of Registered Nurses' Knowledge of Pressure Ulcers Prevention and Treatment’. The first study ‘Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions’ conducted by the authors K. Vanderwee, M. H. F. Grypdonck, D. De Bacquer & Tom Defloor, was published in the Journal of Advanced Nursing in the year 2007 [KVa07]. This study reports the findings of a randomised control trial which was carried out with the aim of determining whether frequent repositioning was an effective preventative strategy for the development of pressure ulcers. As discussed above, repositioning is one of the strategies used in the management of patients who are at risk of developing pressure ulcers and is recognised as an effective measure for preventing pressure sores from developing[Pan92]. However, till date, only a handful of studies have been reported in literature which have investigated the optimal turning frequencies for the prevention of pressure ulcers from developing. And thus, in order to elucidate whether the frequency of turning was associated with prevention of pressure sores from developing and to determine the optimal turning frequencies, this study was carried out. The objective or the study question was to elucidate whether repositioning patients alternately 2 hours in a lateral position and 4 hours in a supine position reduced the incidence of pressure ulcer lesions as compared to repositioning every 4 hours in patients lying on a pressure-reducing mattress. This objective is focused and the authors have clearly defined the proposed intervention and the outcome (i.e. the incidence of pressure ulcers). However, the authors have not mentioned the study population in the study question, i.e. residents of elder care nursing homes and should have done so to make the objective more focused. The study design chosen by the authors, i.e. a randomised control trial, is appropriately suited for this type of question which intended to compare two different interventions, as a RCT is the gold standard for testing the efficacy of a proposed intervention. The study population selected was appropriate as it comprised of individuals residing in 16 different elder care nursing homes. Moreover, since the length of stay in nursing homes is usually longer as compared to that in hospitals, residents of a nursing home are truly at risk of developing pressure ulcers and thus were an appropriately chosen group for monitoring the outcome in question. The control group and the intervention was appropriately chosen as the intervention used for the control group, i.e. 4 hourly repositioning patients lying on a pressure-reducing mattress, is the existing standard of care. One of the purposes of an RCT is to test the efficacy of the proposed intervention against the existing standard of care and since current guidelines propose 4 hourly repositioning on a pressure reducing mattress and 2 hourly repositioning without a pressure reducing mattress, the intervention provided to the control group was the existing standard of care[Def05]. Both the groups were treated equally in all other regards, e.g. the seating procedure, etc. except for the allocated treatment as described in the methodology section under the section of intervention[KVa07]. The inclusion criteria for the participants are clearly mentioned, however, no particular exclusion criteria have been defined. The randomisation was carried out at the ward level using randomization lists generated with SPSS 12. Each ward was included in the study for a period of 5 weeks. The use of this 5 week period was selected by the authors in order to ensure adherence to the study protocols. However, no other details of the randomisation process are defined including whether stratification was carried out or not have been provided in the methodology. Moreover, the study was not double blinded, as it ideally should be, because the nurses providing the intervention and assessing outcomes were not blind to the intervention being provided. However, this limitation was accounted for by the high rates of inter-rater reliability which show that there was minimal bias[KVa07]. The two groups were found to be comparable in their baseline characteristics. The patients in both groups were followed on a daily basis but there is ambiguity regarding the total time for which the patients were followed. The authors do mention the median time of follow up for both groups, but whether there was a standard time duration for which the patients were followed, and the rationale for following the patients for that period of time is not provided. It is also unclear whether the time period for follow up used was adequate to study the effects of the intervention, as the mean time for the development of pressure ulcers after the exposure to friction, shear forces or pressure, has been reported to be approximately 3 days in literature[Red90]. The outcome, i.e. development of pressure ulcers in both groups, was assessed using two measures, viz. the EPUAP classification system for the grading of ulcers and the Braden Scale[Bra94] which is used to assess pressure ulcer risk. Both these tools are validated and reliable measures of the outcome in question. The authors have provided a flowchart accounting for all the participants approached for participation in the study and those who were recruited and eventually completed the study. According to the flowchart, 100% of the patients who were recruited in the study and randomised in to the two groups completed the study and all individuals were analysed in the group they were assigned to[KVa07]. The prevalence of pressure ulcers in this population was found to 9.9%, which is comparable to other studies conducted previously, as discussed above. The treatment effect was described using incidence, incidence rate and relative risk. The incidence was found to 16.4% vs. 21.2% in the experimental and control groups, respectively and the incidence rate was found to be 10.3 per 1000 days vs. 15.6 per 1000 days amongst the two groups[KVa07]. No statistically significant difference was found between the incidence or incidence rates amongst the two groups. The relative risk (RR) was found to be 0.66. All the confidence intervals mentioned in the results were narrow which implies that the results were precise. However, the confidence intervals reported in all cases (i.e. for incidence, incidence rates and relative risk) included 1 which denotes that there were no statistically significant differences amongst the two groups with regards to the variables being studied[KVa07]. One of the secondary objectives of this study was to predict factors associated with increased risk of developing pressure ulcers. However, the authors could not elucidate any significant predictive factors. In this study, the intervention found to be ineffective. Therefore, no benefits of the proposed treatment were found. Moreover, the authors reported that frequent turning associated with additional costs and manual labour and is uncomfortable for the patients, which are some of the limitations of the proposed treatment strategy. The limitations of this study include the fact that the nurses could not be blinded to the intervention being provided and that the number of participants recruited was lesser than the sample size calculated. The results of this study are generalizable to the population of UK due to its large sample size and the fact that the patients were recruited from 16 different elder care centres. However, one limitation which was not mentioned by the authors was the fact that approximately 83 % of the study participants were female. This limits the generalizability of the results of this study to the rest of the population as there may be different factors influencing the development, progression and resolution of pressure ulcers amongst the two sexes. The authors also identified certain shortcomings in the existing standard of care. It was found that the use of an ordinary pillow for positioning the patients in a 30ₒ lateral position was ineffective as patients frequently tended to turn back to supine position[KVa07]. This opens an arena for further research, which should aim at developing a solution for this problem such as a positioning cushion to aid patients in achieving a more stable and comfortable lateral position. In conclusion, this study was an overall well conducted study. The results proved that frequent repositioning of patients is an ineffective measure in the prevention of pressure ulcers, which is an important finding, as excessive frequent repositioning has its own perils, which have been discussed above. This study is the first of its kind in elucidating the efficacy of this intervention and lays down the foundation for future studies in this arena. The second study, ‘An Assessment of Registered Nurses' Knowledge of Pressure Ulcers Prevention and Treatment’ by the authors Diane Smith and Shirley Waugh was published in the journal The Kansas Nurse in the year 2009. This was a descriptive study which aimed at determining the knowledge regarding the risk factors for the development of pressure ulcers, staging and wound description of pressure ulcers and preventive factors, amongst registered nurses, and had a secondary objective of determining the barriers to the provision of optimal treatment and prevention by the nurses[Dia09]. As discussed before, nurses are the keyplayers in the provision of effective management for pressure ulcers. Studies have revealed that the standard of care provided by the nurses is directly associated with the existing level of knowledge and education regarding that area of care amongst involved health care personnel[Ame05]. This study was a descriptive study regarding the knowledge of nurses regarding pressure ulcers at a particular institution. The study design selected is appropriate for this kind of objective which was to evaluate the knowledge regarding a specific topic amongst the study participants. No specific strategy for the recruitment of study participants has been mentioned and a convenient sampling method was used. The study was conducted at a single hospital in the Midwest. The outcome was assessed using the Pieper Pressure Ulcer Knowledge Test which is a prevalidated, reliable outcome assessment tool, as established by previously conducted studies in this regard[Dia09]. The response rate for this study was extremely low, i.e. 22% and no explanation for such a low response rates has been provided by the authors. The mean test scores found in this study were comparable to previously conducted studies. It was found that recent updates in knowledge regarding pressure ulcers by means of reading a book or an article, or via the internet on the part of the nurses was associated with higher test scores. Moreover, it was found that 54% were faced with barriers in the provision of effective management of pressure ulcers, with time constraints and logistic factors such as inadequate help available and the patient being too heavy to manage, being amongst the most common barriers identified[Dia09]. This study has several limitations. One of the greatest limitations is the small sample size and the very low response rate. Moreover, voluntary participation and the fact that the study was limited to only a single hospital may have resulted in selection bias and thus the sample collected cannot be considered a representative sample of the nursing population. Moreover, since certain items on the questionnaire required nurses to recall incidents from memory, this may have lead to recall bias on the part of the nurses. In addition, the time provided to the nurses to fill the outcome assessment questionnaire was inadequate and this limits the reliability of the findings[Dia09]. This study lays down foundation for future research and stresses the importance of introducing regular educational programs and activities amongst nurses, such as CMEs (Continuing Medical Education) in order to update their knowledge regarding specialized areas of care that they are involved in. In conclusion, this study was a very weak study with various limitations in its design and methodology. The findings of this study confirm the findings previously established in literature and this study did not reveal any significant new findings. Conclusions: Thus, pressure ulcers are a commonly encountered health care problem not only in the United Kingdom but throughout the world. In the UK, , the prevalence for pressure ulcers ranging between 10% to 33% has been reported and this problem poses a significant health care and economic burden. Nurses play a pivotal role in the provision and delivery of pressure ulcer management. Therefore, they should be properly educated and should posses adequate knowledge regarding this aspect of health care. Several strategies for the prevention and management of pressure ulcers exist, including provision of wound care, pressure relief, frequent repositioning, surgical debridement and nutritional rehabilitation. There are however certain gaps in literature which still exist, such as the optimal frequency of repositioning and the role of novel treatment modalities in pressure ulcer management which needs to be explored further. Thus, further research in these aspects is warranted. References Jos061: , (Grey, Enoch, & Harding, 2006), Pre94: , (Bick & Stephens, 2003), Bes08: , (Best Practice Guidelines, 2008), Eur10: , (European Pressure Ulcer Advisory Panel (EPUAP), 2010), Def05: , (Defloor, Grypdonck, & Bacquer, 2005), KVa07: , (Vanderwee, Grypdonck, Bacquer, & Defloor, 2007), Pan92: , (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992), Red90: , (Reddy, 1990), Bra94: , (Braden & Bergstrom, 1994), Dia09: , (Smith & Waugh, 2009), Ame05: , (Ameen, Coll, & Peters, 2005), Read More