Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument.

BACKGROUND: Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity. METHODS: A descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T. After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012. RESULTS: Thirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses. CONCLUSIONS: The pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it's impact on care processes and patient outcomes.

The cost of pressure ulcers in the United Kingdom.

OBJECTIVE: To provide an estimate of the costs of treating pressure ulcers in the UK at August 2011 prices, as a means of highlighting the importance of pressure ulcer prevention. METHOD: Resource use was derived from a bottom-up methodology, based on the daily resources required to deliver protocols of care reflecting good clinical practice, with prices reflecting costs to the health and social care system in the UK. This approach was used to estimate treatment costs per episode of care and per patient for ulcers of different severity and level of complications. RESULTS: The cost of treating a pressure ulcer varies from £1,214 (category 1) to £14,108 (category IV). Costs increase with ulcer severity because the time to heal is longer and the incidence of complications is higher in more severe cases. CONCLUSION: Pressure ulcers represent a significant cost burden in the UK, both to patients and to health-care providers. Without concerted effort, this cost is likely to increase in the future as the population ages. The estimates reported here provide a basis for assessment of the cost-effectiveness of measures to reduce the incidence of hospital-acquired ulcers. DECLARATION OF INTEREST: Heron Evidence Development Ltd. was funded for this work by Mölnlycke Health Care (UK). The authors have no other conflicts of interest to declare.

Use of granulated sugar therapy in the management of sloughy or necrotic wounds: a pilot study.

OBJECTIVE: To determine the in vitro antimicrobial efficacy of three types of sugar and conduct a pilot clinical study with a view to developing a protocol for a randomised controlled trial (RCT). METHOD: In the in vitro studies three types of granulated sugar (Demerara, granulated beet sugar and granulated cane sugar) were tested to determine their minimum inhibitory concentrations (MICs) against 18 Gram-negative and Gram-positive bacteria in a micro-titre broth dilution assay; growth inhibition of Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa in different concentrations of sugar (0.38-25%) was also tested over 12-hours in an agar diffusion assay. The pilot clinical study selected patients from a vascular surgical ward and a vascular outpatient department. All had acute or chronic exuding wounds, some of which were infected. White granulated sugar was applied to the wounds. The following parameters were assessed: surface area; wound characteristics including pain, malodour, appearance (slough/granulation); exudate level; pain level and bacterial load. Patients with diabetes had their blood sugar levels checked daily. All patients completed a short health questionnaire at the start and end of the study. Staff completed a satisfaction questionnaire at the end of the study. The study period was 21 days. RESULTS: In vitro tests demonstrated that sugar inhibits bacterial growth. All three types of sugars had MICs ranging from 6-25% in the bacterial strains tested. The diffusion tests showed that strains were able to grow well in low concentrations of sugar but were completely inhibited in higher concentrations. The two granulated sugars were found to be slightly more effective than Demerara sugar, so the latter was excluded from the clinical pilot study. Twenty-two patients (20 inpatients and two outpatients) with sloughy or necrotic wounds were recruited into the clinical study. Two patients had MRSA and two had Staphylococcus colonisation at baseline. Blood sugar levels remained stable in the seven patients with insulin-dependent diabetes mellitus. All wounds were clean/debrided in a mean of 11.13 days. Pain and malodour reduced markedly. Patient and staff surveys revealed overwhelming support for the sugar therapy. CONCLUSION: The pilot study achieved its aim of developing a protocol for a RCT. Preliminary data suggest that sugar is an effective wound cleansing and is safe to use in patients with insulin-dependent diabetes. In vitro studies demonstrate that sugar inhibits bacterial growth. CONFLICT OF INTEREST: None.

A joint collaboration: international pressure ulcer guidelines.

After four years in development, the EPUAP and the NPUAP are ready to release their joint, international, evidence-based pressure ulcer guidelines. This article considers the practice implications of a selection of the new guideline's statements.

A study comparing two objective methods of quantifying the production of wound exudate.

OBJECTIVE: The objective assessment of chronic wound therapies for exudate management (WRAP study) tested a variety of methods that could be used to improve understanding of dressing performance in the presence of wound exudate, including measurement of the levels of exudate production. The aim of this study was to identify a valid and reliable method of measuring wound exudate production per unit area of wound surface. METHOD: Two methods were tested. Method A measured the weight of exudate collected in dressings by 'before and after' weighing of all dressing materials that came into contact with wound exudate. Method B measured wound exudate collected as part of topical negative pressure (TNP) therapy. RESULTS: Method A: Complete data were collected on three patients (at which point the study was halted), but it was only possible to obtain accurate measurements for two of these. Exudate production was 0.10g/cm2/24 hours and 0.21g/cm2/24 hours. It was time-consuming and required special equipment. Method B: Fifteen measurements from five patients were analysed and showed a mean exudate production of 1.3g/cm2/24 hours. CONCLUSION: There are problems with both methods of exudate measurement, but measuring wound fluid collected inTNP canisters seems simpler than weighing dressings and deserves further investigation.

Using protective skin wipes under adhesive tapes.

An assessment of a trial of a protective skin wipe for patients with a reaction to adhesive tapes.

Pressure area care and estimating the cost of pressure sores.

Three reviewers critique the article cited below and assess its influence on the management of pressure sores, both in hospital and in community care.

Letters.

SURGICAL DEBRIDEMENT CORRECTION.

Profiling beds versus standard hospital beds: effects on pressure ulcer incidence outcomes.

Most standard hospital beds are flat based with a pull-out backrest, resulting in a tendency for the patient to slide down the bed. This study aimed to compare the outcome for patients at high risk of developing pressure ulcers nursed on either this type of bed or an electrically operated, multi-sectioned profiling bed. A total of 100 patients were randomly assigned either to the profiling bed with a pressure-reducing foam mattress (experimental group) or a flat-based bed with an appropriate pressure-redistributing mattress (control group) for a maximum of 10 days. Risk status and pressure damage were assessed daily. Both a patient and a nurse questionnaire were completed. Data from 70 patients who participated in the study for five days or more were included in the analysis. Pressure ulcer incidence was 0% in both groups. All patients (35) in the experimental group were able to maintain a sitting position compared with only 12/35 in the control group (p = 0.0001). While the questionnaire results suggest there were significant differences in postural control and ease of transfer between patients in the two groups, it was not possible to map this to pressure ulcer formation. Poor recruitment into the study was due to the 'blocking' of electric beds by heavily dependent patients who did not meet the inclusion criteria, precluding a significant result in terms of pressure ulcer outcomes. This nurse-led use of the profiling beds was examined alongside the main study to investigate why they were allocated in this way.

Letters.

ANTIBIOTICS AND OLDER PEOPLE PATIENT CONFIDENTIALITY RESEARCH ON LEG ULCERS INFECTION AND SOCIAL HAND-WASHING WATER, WATER EVERYWHERE.

Case study methodology in tissue viability. Part 1: Methodological considerations.

Case studies are often presented in relation to tissue viability problems. Within hierarchies of evidence, case studies are sometimes seen to be on a par with expert opinion. This paper examines the case study as a research method and seeks to determine its value in tissue viability research. The term 'case study' denotes a general strategy for research where several methods of data collection are used to provide an in-depth analysis of an individual, group or institution. Three types of case study are used in research: intrinsic, instrumental and collective. All case studies utilize data triangulation within their design, that is, the use of a variety of sources of data within a study. It is one of the major strengths of the case study method. Data sources include documentary data sources, observation and interviews. As in any research, validity and reliability are important in case study methodology; in particular, construct validity, internal validity and external validity. Case studies are potentially vulnerable to observer error and observer bias. Examples are given of potential case studies in tissue viability and their strengths and weaknesses. If undertaken prospectively, with clearly defined multiple sources of data collection and a documented chain of evidence, case studies can add breadth to our knowledge and experience of caring for patients with tissue viability problems.

Case study methodology in tissue viability. Part 2: A study to determine the levels of knowledge of nurses providing care for patients with leg ulcers in an acute hospital setting.

One of the main components of the clinical governance framework is a comprehensive programme of quality improvement activity that includes the implementation of evidence-based, everyday clinical practice. This paper addresses the challenges surrounding the implementation of one area of evidence-based practice, the management of leg ulcers in an acute hospital trust. The aim of the study was to distinguish the levels of knowledge of nurses providing care for patients with leg ulcers within an acute hospital setting. The design used was that of a collective case study. Each 'case' was a patient with a leg ulcer and the nurses who cared for that patient. They were studied in order to provide insight into the nurses' understanding of leg ulcer management. A number of themes were identified as being common to all the cases. They are: evidence-based practice, nursing skills, quality of life, patient understanding of their ulcer and pain. Each of these themes identified areas of knowledge deficit in the nurses. As part of the implementation of a leg ulcer policy an education programme is being developed to address these deficits.

Pressure ulcer prevention--the UK perspective.

Pressure ulcers are a universal problem. Much attention has been given to them in the United Kingdom in recent years. They are seen as a key indicator of the quality of care. Their prevention has become politically, as well as clinically, important.

Role of hydrocolloids in wound management.

This article describes the actions of hydrocolloid dressings and the type of wounds for which they are most suitable. The range of hydrocolloid products is reviewed along with their individual advantages and disadvantages.

Common problems in wound care: caring for the skin around wounds.

This article is the first in a monthly series which will address some of the common problems in wound care. Each article will discuss the nature of the problem and suggest appropriate management strategies.

Measuring the prevalence and incidence of pressure sores.

There is increasing interest in measuring the prevalence and incidence of pressure sores. These terms are often poorly understood and sometimes used interchangeably, although they refer to different forms of data collection. This article seeks to clarify the differences between them.

The background to the national clinical guidelines for the prevention and management of pressure sores.

Clinical guidelines are systematically developed statements to assist health-care professionals in decision-making and should be viewed as a means of improving clinical effectiveness. The NHS Executive wishes to encourage their development and use. To this end it has commissioned a number of clinical guidelines. As these will be used in a number of health-care settings, the need for multiagency and multiprofessional care is recognized. The main themes of the guidelines are that care should be patient focused, clinically useful and multidisciplinary. This article introduces a monthly series in the British Journal of Nursing examining the national clinical guidelines for pressure sore prevention and management.

Obtaining the evidence for clinically effective wound care.

In tissue viability, as in other aspects of health care, there is increasing recognition of the need for healthcare interventions to be supported by good research evidence. The randomized controlled trial (RCT) is considered to provide the most accurate evidence of effectiveness. This article discusses some of the problems that arise when researchers attempt to obtain the relevant evidence. They include funding, sample selection, sample size, recruitment of patients, and mortality and attrition rates. These points are illustrated by means of a case study. In this study an RCT was undertaken to compare two dressings for the management of pressure sores. Problems arose with recruitment of patients to the study. Relevant issues associated with this are discussed and recommendations for future recruitment are presented.

Measuring the size of the leg ulcer problem in an acute trust.

The majority of patients with leg ulceration are cared for in the community. There is insufficient evidence of the numbers of these patients who are being cared for in acute hospitals. This study sought to identify the size of the problem in one acute trust by means of a point prevalence survey. From a study population of 931 patients, 17 had leg ulcers, giving a prevalence of 1.8%. Out of 52 wards and units, staff on 44 (84.6%) said that patients with leg ulcers were admitted on occasion. In the case of 19 (36.5%) wards and units this was as infrequently as one or two patients a year. The results of this survey have considerable implications for ensuring that all patients receive optimum care.