Comparison of two skin protection regimes for the Prevention of Incontinence-associated Dermatitis in geriatric care (PID): a study protocol for an exploratory randomised controlled pragmatic trial.

INTRODUCTION: The majority of aged long-term care receivers and patients in geriatric acute care are affected by some form of incontinence. These individuals are at risk of developing incontinence-associated dermatitis (IAD), a common type of irritant contact dermatitis caused by repeated and prolonged direct contact of the skin with urine and stool. The prevalence of IAD in these settings is high. Preventive measures include mild skin cleansing and the application of skin protecting leave-on products. Available evidence is weak regarding the comparative performance of different skin protection strategies and products due to a lack of confirmatory trials using relevant comparators and endpoints. Therefore, the overall aim of this exploratory trial is to compare the effects of three skin protection strategies to estimate effect sizes of the recently published core outcomes in IAD research. METHODS AND ANALYSIS: A pragmatic three-arm, assessor-blinded, randomised controlled, exploratory trial with parallel group design will be performed, comparing film-forming and lipophilic skin protecting leave-on products for IAD prevention with standard incontinence care alone. The trial will be conducted in geriatric nursing homes and geriatric acute care settings in the federal state of Berlin, Germany. A total of n=210 participants being incontinent of urine and stool will be included. Outcomes include IAD incidence, erythema, erosion, maceration, IAD-related pain, patient satisfaction, safety, feasibility and compliance. IAD incidence of the control and intervention groups will be compared to estimate effect sizes, and the procedural feasibility of the intervention will be tested to plan a possible subsequent confirmatory randomised controlled trial. ETHICS AND DISSEMINATION: The study received the approval of the ethics committee of Charité-Universitätsmedizin Berlin (EA4/043/22). Results will be disseminated through peer-reviewed open-access journals and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT05403762) and German Clinical Trials Register (Deutsches Register Klinischer Studien, or DRKS) (DRKS00028954).

Prevalence and risk factors of chronic wounds in nursing homes in Germany: A Cross-Sectional Study.

The burdens caused by chronic wounds on the affected persons themselves and also on the health care system are well recognised. The aim of this study was to investigate the prevalence and risk factors of chronic wounds in German nursing homes. An annual cross-sectional study was conducted in nursing home residents from 2012 to 2018. The proportion of men affected by chronic wounds was to some extent higher than that of women, 9.0% males vs 7.5% females. In total, 7.8% of all residents were affected by chronic wounds. Of all residents with a chronic wound, 50.5% were affected by pressure ulcer. Male residents were twice as often affected by diabetic foot ulcer than female residents (18.0% vs 8.9%; P = 0.002). Bivariate analysis showed that chronic wounds were highly associated with poor nutrition, urinary incontinence, stool incontinence, diabetes mellitus, and limited mobility (P = 0.000). According to multivariate analysis, the strongest predictors for chronic wounds were limited mobility and diabetes mellitus. The highest prevalence of chronic wounds was in residents who were not restricted in their mobility, had diabetes, were male, and lived in a metropolitan region (23.7%). This study identified the prevalence and risk factors of chronic wounds in nursing home residents. Further research is needed to identify causal factors of the gender difference in the prevalence of chronic wounds. This may have an impact on the choice of prophylactic and therapeutic measures.

[Prevalence and influencing factors of chronic wounds among clients of home care services in Germany]. / Prävalenz und Einflussfaktoren von chronischen Wunden bei Klienten von ambulanten Pflegediensten in Deutschland.

INTRODUCTION: Chronic or non-healing wounds are a serious problem for both the parties involved and the healthcare system. Currently, there are hardly any reliable data on the prevalence of chronic wounds in outpatient care, although this setting is becoming increasingly important. Therefore, the aim of this study was to determine the prevalence of and the factors associated with chronic wounds in clients cared for by home care services. METHOD: As part of a cross-sectional study throughout Germany in 2012, a survey was conducted among care recipients provided by home care services. The sample was drawn in a two-step procedure. First, a random sample of home care services was drawn for each federal state, followed by random selection of clients to be interviewed for each service. The aim of the study was to describe the prevalence of chronic wounds and influencing factors such as BMI, age, housing situation, activity and diabetes mellitus. Data collection through questionnaire was carried out by trained nurses. RESULTS: A total of 144 home care services with 1,296 clients had agreed to participate. With 880 care recipients from 100 home care services finally taking part in the survey, the response rate was 68 %. Of all care recipients examined, 101 had at least one chronic wound; the highest prevalence rates were observed for pressure ulcers (4.6 %) and leg ulcers (4.0 %). Care recipients with diabetes mellitus were more frequently affected by chronic wounds (16.4 %) than non-diabetic recipients (9.5 %). Community-living care recipients (14.1 % chronic wounds; 6.0 % pressure ulcers) and care recipients under the age of 65 (20 % chronic wounds; 9.5 % pressure ulcers) were affected more frequently than care recipients living alone (9.1 % chronic wounds; 3.0 % pressure ulcers) or care recipients older than 65 years (10.5 % chronic wounds; 4.0 % pressure ulcers). In the multivariate calculation, the BMI proved to be the strongest predictor. The prevalence of chronic wounds in the group of obese (BMI>35.3kg/m2) care recipients and those with activity restriction is 44.8 %. CONCLUSION: In view of the fact that one out of nine care recipients receiving assistance from home care services is affected by at least one non-healing wound, special attention should be paid to the prevention, detection and treatment of chronic wounds. Furthermore, it seems particularly necessary to identify the relevant risk groups in order to be able to initiate adequate and preventive measures at an early stage.

[Structure Parameters and Quality Outcomes of Ambulant Home-care]. / Strukturparameter und pflegerische Ergebnisqualität in der ambulanten Pflege.

INTRODUCTION: So far, there are few data available on the changes of ambulant home-care in Germany over the last decades. Therefore, the aim of this research was to provide structure data on nursing personnel, funding, size, regional differences, and training needs of ambulant home-care services in Germany. In addition, a possible association between structure parameters and quality outcomes for pressure ulcer and malnutrition was investigated. METHODS: In 2015, a multicenter cross-sectional study was conducted in home-care services in Germany. Structure data from 99 randomly selected home-care services as well as data on pressure ulcers and malnutrition of 903 care-dependent clients were analyzed. The median (<98 clients) was used as a cut-off to differentiate between small and large home-care services. From a cut-off of 20,000 inhabitants, a region was considered urban. The average prevalence for decubitus and malnutrition (BMI<20 Kg/m2) were determined for each home-care service, and possible associations with structure parameters were analyzed using a multiple linear regression model. RESULTS: The proportion of registered nurses in non-private (private) home-care services was 60.6% (52.3%). The proportion of employees with a 200- h basic qualification in nursing was higher in private (12.5 vs. 4.7%), small home-care services (14.0 vs. 5.8%) and in urban regions (11.5 vs 5.7%). In average, registered nurses working in small home-care services spent significantly more time per client than the ones working in large services (3.8 vs. 2.9 h/week). The highest need for further training was shown on the subjects of pain, medication and cognitive impairment. No statistically significant correlation could be found between the average decubitus prevalence and structure parameters. Only the association between malnutrition prevalence and the proportion of registered nurses was statistically significant. CONCLUSION: The present representative study provides structure data on nursing personnel, funding, size, regional differences, and training needs of ambulant home-care services in Germany that could be used as a baseline for further investigations. No statistically significant association could be found between structure and outcome quality parameters. There is a need for further training of nursing personnel on the subjects of medication, pain and cognitive impairment.

Mobility is the key! Trends and associations of common care problems in German long-term care facilities from 2008 to 2012.

BACKGROUND: Although enormous efforts have been made in auditing the quality of care, there are only few epidemiological studies available about the actual occurrence of immobility, malnutrition, urinary incontinence, cognitive impairment, falls and pressure ulcers in long-term care facilities. OBJECTIVE: The objective of this study was to provide prevalence estimates of common nursing care problems in long-term care facilities and to investigate any associations between them. DESIGN: Secondary data analysis of five consecutive annual cross-sectional multicenter studies from 2008 to 2012. SETTING: 262 different long-term care facilities throughout Germany. PARTICIPANTS: 14,798 residents older than 18 years who gave informed consent. METHODS: Health conditions were rated based on direct resident examinations according to the current international definitions. Demographic characteristics were compared with available national population statistics. Apart from descriptive statistics, Chi(2) tests were carried out for bivariate and log-regression models were performed for multivariate associations. RESULTS: Prevalence rates were stable over the years with the highest prevalence of 73.5% (95% CI 72.8-74.2) being found for urinary incontinence, for cognitive impairment it was 54.1% (95% CI 53.3-54.9) and for immobility it was 36.5% (95% CI 35.7-37.3). The lowest prevalence rates were established for the risk of malnutrition with 13.0 (95% CI 12.4-13.5), for pressure ulcers with 4.8% (95% CI 4.5-5.1) and for falls (4.4% 95% CI 4.1-4.8). In the multivariate model, immobility was most strongly associated with all of the other conditions. No statistically significant associations were found between pressure ulcers and falls, pressure ulcers and urinary incontinence, pressure ulcers and cognitive impairment and between malnutrition and urinary incontinence. CONCLUSION: Decision-makers and clinical practitioners may primarily focus on the maintenance and enhancement of mobility, because this seems to be the key predictor for many other health conditions in the context of care dependency in the nursing home setting.

The use of fall prevention guidelines in German hospitals - a multilevel analysis.

AIMS: Falls and fall-related injuries are major problems in hospitals. The aim of this study was to examine the impact of fall prevention guidelines on falls and fall-related injuries in hospitals. METHOD: A cross-sectional study was conducted in German hospitals. Some 28 hospitals participated with a total of 5046 patients. Eleven of these hospitals had already implemented a fall prevention guideline, 10 were in the process of developing such a guideline and seven hospitals were not using any fall prevention guideline at all. A standardized questionnaire was used on the individual patient level to obtain details regarding the socio-demographic background, falls, fall-related injuries and other problems relevant to nursing. A further questionnaire referred to the use of fall prevention guidelines in the individual hospitals. Data specific to falls were analysed both on hospital level and on ward and patient level by means of a multilevel logistic model. RESULTS: The univariate analyses suggest that patients in hospitals that are using guidelines are more likely to fall [odds ratios (OR) = 1.19, confidential interval (CI) = 0.65-2.18] than in hospitals that do not use any guideline (reference category) or are still in the developing stage (OR = 0.82, KI = 0.77-0.87). If, in a multivariate analysis, the ward level and individual patient variables (age, disorientation, confusion, incontinence) are included, the following results are obtained: the probability of falls in hospitals not using guidelines (reference category) is higher than in hospitals developing a guideline (OR = 0.86, KI = 0.58-1.28) or using a guideline (OR = 0.71, KI = 0.44-1.14). The differences are even more distinct regarding the injuries resulting from a fall that require medical treatment. The probability of these injuries is significantly lower in hospitals using guidelines (OR = 0.27, KI = 0.09-0.85) than in hospitals developing a guideline (OR = 0.61, KI = 0.24-1.54) or not using any guidelines at all (reference category). CONCLUSION: The present results of the multilevel analysis show that falls and fall-related injuries can be reduced by the implementation of fall prevention guidelines.

A systematic review of interrater reliability of pressure ulcer classification systems.

AIMS: To review systematically the interrater reliability of pressure ulcer classification systems to find out which classification should be used in daily practice. BACKGROUND: Pressure ulcer classification systems are important tools in research and practice. They aim at providing accurate and precise communication, documentation and treatment decisions. Pressure ulcer classifications are criticised for their low degree of interrater reliability. DESIGN: Systematic review. METHODS: The data bases MEDLINE, EMBASE, CINAHL and the World Wide Web were searched. Original research studies estimating interrater reliability of pressure ulcer classification systems were included. Study selection, data extraction and quality assessment was conducted independently by two reviewers. RESULTS: Twenty-four out of 339 potentially relevant studies were included in the final data synthesis. Due to the heterogeneity of the studies a meaningful comparison was impossible. CONCLUSIONS: There is at present not enough evidence to recommend a specific pressure ulcer classification system for use in daily practice. Interrater reliability studies are required, in which comparable raters apply different pressure ulcer classification systems to comparable samples. RELEVANCE TO CLINICAL PRACTICE: It is necessary to determine the interrater reliability of pressure ulcer classifications among all users in clinical practice. If interrater reliability is low the use of those systems is questionable. On the basis of this review there are no recommendations as to which system is to be given preference.