The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence.

BACKGROUND: In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study. AIM: Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee]. METHOD: A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions. RESULTS: Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities. CONCLUSION: It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.

Prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units. Results of a cross-sectional survey.

OBJECTIVE: Evaluating the prevalence, risk factors and prevention of pressure ulcers in Dutch intensive care units (ICUs). DESIGN: Cross-sectional design. SETTING: ICUs of acute care hospitals that participated in the 1998 and 1999 national prevalence surveys. Data were collected on 1 day in each year. PATIENTS: Eight hundred fifty patients admitted to Dutch ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six categories of data were collected: (1) characteristics of the institution, (2) characteristics of the ward, (3) characteristics of the patients (age, sex, date of admission, reason for admission), (4) risk assessment using the Braden scale and two additional risk factors (malnutrition and incontinence), (5) severity of the pressure ulcers and (6) supportive surface used. The prevalence of pressure ulcers was 28.7%. In a forward logistic regression analysis, four risk factors were significantly associated with the presence of pressure ulcers: infection, age, length of stay and total Braden score. Of the patients at high risk of developing pressure ulcers but without actual pressure ulcers, 60.5% were positioned on a support system. Only 36.8% of the patients who were determined to need repositioning were actually being turned. CONCLUSIONS: The prevalence of pressure ulcers in Dutch ICUs is high and their prevention is flawed, especially as regards the use of support systems. Patients for whom turning is indicated are not being turned. Predicting pressure ulcers in ICU patients is difficult and needs further investigation.

Relevance of the diagnosis 'stage 1 pressure ulcer': an empirical study of the clinical course of stage 1 ulcers in acute care and long-term care hospital populations.

Stage 1 pressure ulcers are difficult to diagnose. Several prevalence studies have shown that almost half of the pressure ulcers identified are stage 1. The present study investigated the importance of stage 1. The following research questions were formulated: Is there a difference between the prevalence of stage 1 pressure ulcers identified in the institutions participating in the present study and that found in the other institutions participating in the Dutch National Prevalence Survey? What percentage of stage 1 pressure ulcers are reversible within a few hours? What is the clinical course of stage 1 pressure ulcers? Which patient characteristics and preventive interventions are related to the clinical course of stage 1? The study used a prospective, descriptive and comparative design. All patients of six long-term care hospitals and six acute care hospitals in whom stage 1 pressure ulcers were identified during the 1999 National Prevalence Survey in the Netherlands were followed for 1 week (acute care hospitals; n = 68 patients) or 2 weeks (long-term care hospitals; n = 115 patients). The patients were reassessed using the questionnaire developed for the National Prevalence Survey (patient characteristics, assessment of risk of pressure ulcers, characteristics of the pressure ulcers and use of preventive methods) on the same day as the national survey itself, and again after 3 days, after 7 days and after 14 days (only long-term care hospitals). The results showed fewer stage 1 pressure ulcers in the institutions participating in the present study than in the National Prevalence Survey, the difference being almost 50%. The first reassessment found the prevalence of stage 1 to be further reduced by an average of almost 50%, a reduction which was greater for the long-term care hospitals than for the acute care hospitals. However, some of the ulcers that had disappeared reappeared in subsequent reassessments. In the long-term care hospitals, 8.7% of the stage 1 pressure ulcers deteriorated to a higher stage, vs. 22.1% in acute care hospitals. No significant patient characteristics were found to affect the course of stage 1, except that women in acute care hospitals more often had a stage 1 pressure ulcer at the first reassessment than men. In general, patients whose stage 1 ulcer deteriorated were undergoing more preventive interventions; not all differences were significant. We conclude that, although stage 1 is reversible in most cases, it can be interpreted as an important warning sign for nurses and patients to act. If no adequate interventions are applied, the pressure ulcer may deteriorate.

The development of a national registration form to measure the prevalence of pressure ulcers in The Netherlands.

To gain insight into the prevalence of pressure ulcers in Dutch healthcare institutions, a national registration form to measure the prevalence of pressure ulcers annually in different healthcare settings was developed based on a literature study and responses from a Delphi panel. The reliability and the feasibility of the form devised were tested in a pilot study conducted in a university hospital, a nursing home, and in a home healthcare setting. Interrater reliability of the grading system varied between the institutions from 0.49 to 0.97 (Cohen's Kappa). In the home healthcare setting, interrater reliability was 0.80 (Pearson correlation coefficient) for the total score on the Braden scale. The prevalence rates were 10.1% (n = 368) in the university hospital, 12.7% (n = 1,541) in the home healthcare setting, and 83.6% (n = 122) in the nursing home, although the latter figure seemed to be somewhat exaggerated. The most common lesions were found on the sacrum and below the knee (heel and malleolus). The pilot study concluded that it is possible to collect accurate and reliable data on the scope and severity of pressure ulcers with a uniform instrument in different healthcare settings.

Assessment of pain in the neonate.

This article critically reviews the measures developed for assessing pain in the human neonate. Information was gathered with a computerized literature search of published articles and abstracts, a manual review of relevant conference proceedings, recently published journals, unpublished reports and manuscripts, and personal files. This identified 16 measures that were critically examined for their psychometric properties (reliability and validity) and clinical use. Special emphasis was placed on the feasibility of using neonatal pain assessment measures for clinical practice to address the research-practice gap. Although considerable progress has been made in the field of neonatal pain assessment, few measures have adequately established psychometric properties and clinical utility. Furthermore, most measures have been developed for research and not for the clinical setting. Issues regarding sensitivity, specificity, and the ability to detect clinically important changes have not been addressed. A sufficient number of infant pain measures have now been developed to assess acute pain. There is a paucity of measures to assess chronic pain in infants, and measures for infants who are low birth weight, critically ill, or ventilated. Future research should be aimed at strengthening the properties of existing measures, and at the development of measures for those infants with chronic pain or special needs.

The effects of aftercare on chronic patients and frail elderly patients when discharged from hospital: a systematic review.

The purpose of this systematic review was an assessment of the efficacy of aftercare in chronic patients and the frail elderly when discharged from hospital, as regards quality of life, compliance, costs, medical consumption and quality of care. In pursuit of this goal, 17 publications on the effects of aftercare after discharge from hospital were examined. A systematic assessment of methodological quality by two blinded independent reviewers resulted in a consensus score (0-100 points), based on four categories: the study population, description of the interventions, measurement of the outcome and the analysis and presentation of the data. Only three of the 17 studies scored more than 50 points, indicating that most of the studies were of poor methodological quality. The most prevalent methodological problems were that co-interventions were not avoided, a placebo group was lacking, the assessment was not blinded and the analysis was not made on the basis of the intention-to-treat principle. The majority of the studies did not report clear beneficial effects in favour of the intervention group. The positive effects reported were limited to costs and quality of care.

Burnout in psychiatric nursing: a meta-analysis of related variables.

The purpose of this study was to describe the relative strengths of a number of variables on burnout among psychiatric nurses. A meta-analysis of correlations revealed that burnout was negatively associated with job satisfaction, staff support and involvement with the organization and positively associated with role conflict. The results of the meta-analysis were in line with results of other studies in which different populations were investigated. Therefore, the findings as such are not specific to psychiatric nurses. Based on the literature, three typical risk factors of burnout among psychiatric nurses were found: the patient group the nurse works with, such as patients who are aggressive and suicidal; the inequity in the exchange process between nurses and patients; and the unrealistic expectations of nurses of the patients' potential for rehabilitation.