Effect of e-learning program on risk assessment and pressure ulcer classification - A randomized study.

BACKGROUND: Pressure ulcers (PUs) are a problem in health care. Staff competency is paramount to PU prevention. Education is essential to increase skills in pressure ulcer classification and risk assessment. Currently, no pressure ulcer learning programs are available in Norwegian. OBJECTIVES: Develop and test an e-learning program for assessment of pressure ulcer risk and pressure ulcer classification. DESIGN, PARTICIPANTS AND SETTING: Forty-four nurses working in acute care hospital wards or nursing homes participated and were assigned randomly into two groups: an e-learning program group (intervention) and a traditional classroom lecture group (control). Data was collected immediately before and after training, and again after three months. The study was conducted at one nursing home and two hospitals between May and December 2012. ANALYSIS: Accuracy of risk assessment (five patient cases) and pressure ulcer classification (40 photos [normal skin, pressure ulcer categories I-IV] split in two sets) were measured by comparing nurse evaluations in each of the two groups to a pre-established standard based on ratings by experts in pressure ulcer classification and risk assessment. Inter-rater reliability was measured by exact percent agreement and multi-rater Fleiss kappa. A Mann-Whitney U test was used for continuous sum score variables. RESULTS: An e-learning program did not improve Braden subscale scoring. For pressure ulcer classification, however, the intervention group scored significantly higher than the control group on several of the categories in post-test immediately after training. However, after three months there were no significant differences in classification skills between the groups. CONCLUSION: An e-learning program appears to have a greater effect on the accuracy of pressure ulcer classification than classroom teaching in the short term. For proficiency in Braden scoring, no significant effect of educational methods on learning results was detected.

Patient and organisational variables associated with pressure ulcer prevalence in hospital settings: a multilevel analysis.

OBJECTIVES: To investigate the association of ward-level differences in the odds of hospital-acquired pressure ulcers (HAPUs) with selected ward organisational variables and patient risk factors. DESIGN: Multilevel approach to data from 2 cross-sectional studies. SETTINGS: 4 hospitals in Norway were studied. PARTICIPANTS: 1056 patients at 84 somatic wards. PRIMARY OUTCOME MEASURE: HAPU. RESULTS: Significant variance in the odds of HAPUs was found across wards. A regression model using only organisational variables left a significant variance in the odds of HAPUs across wards but patient variables eliminated the across-ward variance. In the model including organisational and patient variables, significant ward-level HAPU variables were ward type (rehabilitation vs surgery/internal medicine: OR 0.17 (95% CI 0.04 to 0.66)), use of preventive measures (yes vs no: OR 2.02 (95% CI 1.12 to 3.64)) and ward patient safety culture (OR 0.97 (95% CI 0.96 to 0.99)). Significant patient-level predictors were age >70 vs <70 (OR 2.70 (95% CI 1.54 to 4.74)), Braden scale total score (OR 0.73 (95% CI 0.67 to 0.80)) and overweight (body mass index 25-29.99 kg/m(2)) (OR 0.32 (95% CI 0.17 to 0.62)). CONCLUSIONS: The fact that the odds of HAPU varied across wards, and that across-ward variance was reduced when the selected ward-level variables entered the explanatory model, indicates that the HAPU problem may be reduced by ward-level organisation of care improvements, that is, by improving the patient safety culture and implementation of preventive measures. Some wards may prevent pressure ulcers better than other wards. The fact that ward-level variation was eliminated when patient-level HAPU variables were included in the model indicates that even wards with the best HAPU prevention will be challenged by an influx of high-risk patients.

The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: a cross-sectional study.

BACKGROUND: Pressure ulcers are preventable adverse events. Organizational differences may influence the quality of prevention across wards and hospitals. OBJECTIVE: To investigate the prevalence of pressure ulcers, patient-related risk factors, the use of preventive measures and how much of the pressure ulcer variance is at patient, ward and hospital level. DESIGN: A cross-sectional study. SETTING: Six of the 11 invited hospitals in South-Eastern Norway agreed to participate. PARTICIPANTS: Inpatients ≥18 years at 88 somatic hospital wards (N=1209). Patients in paediatric and maternity wards and day surgery patients were excluded. METHODS: The methodology for pressure ulcer prevalence studies developed by the European Pressure Ulcer Advisory Panel was used, including demographic data, the Braden scale, skin assessment, the location and severity of pressure ulcers and preventive measures. Multilevel analysis was used to investigate variance across hierarchical levels. RESULTS: The prevalence was 18.2% for pressure ulcer category I-IV, 7.2% when category I was excluded. Among patients at risk of pressure ulcers, 44.3% had pressure redistributing support surfaces in bed and only 22.3% received planned repositioning in bed. Multilevel analysis showed that although the dominant part of the variance in the occurrence of pressure ulcers was at patient level there was also a significant amount of variance at ward level. There was, however, no significant variance at hospital level. CONCLUSIONS: Pressure ulcer prevalence in this Norwegian sample is similar to comparable European studies. At-risk patients were less likely to receive preventive measures than patients in earlier studies. There was significant variance in the occurrence of pressure ulcers at ward level but not at hospital level, indicating that although interventions for improvement are basically patient related, improvement of procedures and organization at ward level may also be important.

Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture.

OBJECTIVES: To evaluate risk factors for preoperative and postoperative delirium. DESIGN: Prospective cohort study. SETTING: Departments of orthopedic surgery in two Norwegian hospitals. PARTICIPANTS: Three hundred sixty-four patients with and without cognitive impairment, aged 65 and older. MEASUREMENTS: Patients were screened daily for delirium using the Confusion Assessment Method. Established risk factors and risk factors regarded as clinically important according to expert opinion were explored in univariate analyses. Variables associated with the outcomes (P<.05) were entered into multivariate logistic regression models. RESULTS: Delirium was present in 50 of 237 (21.1%) assessable patients preoperatively, whereas 68 of 187 (36.4%) patients developed delirium postoperatively (incident delirium). Multivariate logistic regression identified four risk factors for preoperative delirium: cognitive impairment (adjusted odds ratio (AOR)=4.7, 95% confidence interval (CI)=1.9-11.3), indoor injury (AOR=3.6, 95% CI=1.1-12.2), fever (AOR=3.4, 95% CI=1.5-7.7), and preoperative waiting time (AOR=1.05, 95% CI=1.0-1.1 per hour). Cognitive impairment (AOR=2.9, 95% CI=1.4-6.2), indoor injury (AOR=2.9, 95% CI=1.1-6.3), and body mass index (BMI) less than 20.0 (AOR=2.9, 95% CI=1.3-6.7) were independent and statistically significant risk factors for postoperative delirium. CONCLUSION: Time from admission to operation is a risk factor for preoperative delirium, whereas low BMI is an important risk factor for postoperative delirium in hip fracture patients. Cognitive impairment and indoor injury are independent risk factors for preoperative and postoperative delirium.

Assessment of pain in the nonverbal or cognitively impaired older adult.

The inability of nonverbal older adults to communicate pain represents a major barrier to pain assessment and treatment. This article focuses on nonverbal older adult populations with dementia, delirium, and severe critical illness. A comprehensive approach to pain assessment is advocated encompassing multiple sources of information. Selected behavioral tools for nonverbal pain assessment are critiqued. Although there are tools with promise, there is currently no standardized behavioral tool that may be recommended for broad adoption in clinical practice and continued concerted effort to this end is needed.

Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review.

To improve assessment and management of pain in nonverbal older adults with dementia, an effective means of recognizing and evaluating pain in this vulnerable population is needed. The purpose of this review is to critically evaluate the existing tools used for pain assessment in this population to provide recommendations to clinicians. Ten pain assessment tools based on observation of behavioral indicators for use with nonverbal older adults with dementia were evaluated according to criteria and indicators in five areas: conceptualization, subjects, administration, reliability, and validity. Results indicate that although a number of tools demonstrate potential, existing tools are still in the early stages of development and testing. Currently, there is no standardized tool based on nonverbal behavioral pain indicators in English that may be recommended for broad adoption in clinical practice.