Pressure ulcers in long-term care.

Pressure ulcers are common, costly, and debilitating chronic wounds, which occur preferentially in people with advanced age, physical or cognitive impairments, and multiple comorbidities. Residents with pressure ulcers have decreased quality of life and increased morbidity and mortality, and facilities with high rates of pressure ulcers have higher costs and risks of litigation. Health professionals who practice in this setting should be well versed in pressure ulcer management. This article reviews the significance, risk factors, pathophysiology, prevention, diagnosis, and management of pressure ulcers in long-term care.

A pilot study to explore next of kin's perspectives on end-of-life care in the nursing home.

OBJECTIVES: To explore next-of-kin's (NOK's) perceptions of end-of-life (EOL) care in the nursing home setting and to compare these perceptions for residents receiving hospice care plus usual care versus usual care only. DESIGN: Mailed survey. SETTING: Three nursing homes in central Massachusetts. PARTICIPANTS: Nursing home decedents' NOK MEASUREMENTS: Nursing home decedents' NOK were identified from nursing home records. Survey data were collected on NOK demographics and perceptions of decedents' EOL care. This care included nursing home care and services received by decedents, pain and symptom management, communication about decedents' care, and advance directives. RESULTS: Of 164 surveys mailed, 114 surveys were returned (70% response rate) with 100 completed (61% used for analysis). NOK reported that nursing home decedents had a high symptom burden, with at least 70% experiencing pain, agitation, and/or anxiety, and 60% having shortness of breath or depression. Most NOK reported good-to-excellent symptom control for decedents (88%), feeling well informed about the decedent's condition (91%), satisfaction with medical and nursing care (90%), and the decedent having advance directives in place (89%). Respondents' impressions of decedents' symptom control, communication about decedents' care, level of care, or advance directives did not differ significantly between the hospice plus usual care and usual care only groups. CONCLUSION: In this pilot study, NOK perceived that decedents' EOL care in the nursing home was of similarly good quality under hospice care plus usual care and usual care only. Our study provides an approach to assessing quality of EOL care in the nursing home setting.

An investigation of MRSA infection in a hospice.

This study investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage and infection among patients admitted to a hospice. Under the existing policy at this hospice, only patients admitted from hospital wards where MRSA is known to be present are screened for MRSA prior to transfer. Hence the investigators were keen to study patients transferred from settings other than this. One hundred and twenty patients, all either from the community or from hospital wards without known MRSA, were entered into the study ('study group') and were swabbed for MRSA on admission to the hospice. Swabbing was continued at weekly intervals until discharge or death. Of the 120 patients, seven (5.8%) were MRSA positive on admission. A further four patients who were negative on admission showed MRSA on later swabs. Another two patients developed symptomatic infections during admission that were proven to be due to MRSA, but neither of these had shown MRSA on any swabs taken during the study. During the study period, a separate group of 156 patients was swabbed routinely before transfer from hospital wards where MRSA was known to be present in accordance with hospice policy ('non-study group'). Of these patients, 11 (7.1%) were found to be colonized with MRSA but none developed associated symptomatic infection. It appears that the risk of symptomatic infection with MRSA in hospice patients is low, and the burden placed on this vulnerable group by conventional eradication regimes may be disproportionate to any benefit derived.

Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain.

Pressure ulcer pain, a common problem among palliative care patients, does not respond well to oral analgesics. There have been case reports in the medical literature describing the successful use of topical opioids for painful skin conditions. So far, these topical opioids have not been compared to placebo. To determine the effectiveness of diamorphine gel to control pressure ulcer pain and compare it with placebo, a randomized, double blind, placebo-controlled crossover trial was conducted in 13 patients with painful grade II or III pressure ulcers. Patients resided on the inpatient unit at St. Christopher's Hospice, London, UK. Seven patients completed the study and provided pain scores before and after diamorphine or placebo gel application. Pain scores improved significantly after diamorphine gel application compared with placebo (P<0.05). Diamorphine gel appears to be an effective treatment for pain caused by stage II or III pressure ulcers. It is probably as safe as placebo in regards to side effects, but a larger study would be required to confirm these results.