Incidence, prevalence, and medical costs of pressure injuries in Taiwan from 2001 to 2015: Results of a retrospective cohort study.

AIMS AND OBJECTIVES: This study aims to analyse the trends in the incidence, prevalence and medical costs of pressure injuries (PIs) among genders in Taiwan. BACKGROUND: The treatment of PIs is complex and costly, often leading to complications and increased mortality. This issue significantly impacts healthcare quality and incurs substantial medical and social costs, warranting attention. METHODS: A retrospective cohort study was conducted using data from Taiwan's National Health Insurance Database to obtain and calculate the incidence, prevalence, and medical costs of PIs in the country between 2001 and 2015 as well as to analyse high-risk groups and the medical care utilisation of patients following the STROBE reporting guidelines. RESULTS: Between 2001 and 2015, 15,327 incident case of PIs were diagnosed. During the study period, the prevalence rate of PIs per 100,000 population rose from 26.3 to 189.6, with approximately 11.5%-16.3% of patients undergoing surgical debridement. The PIs prevalence rate increased by 7.2-fold, and hospitalisation costs accounted for 91.7%-96.0% of the total medical costs. Patients with older age, comorbidities, poorer financial status and lower education levels were found to be likely to develop PIs. These predisposing factors differed between males and females. The prevalence of PIs was higher in patients ≥75 years old than in patients from other age groups. Moreover, PI-related medical expenses have been increasing annually. CONCLUSIONS: In Taiwan, the rising incidence of PIs is driving up medical costs. Effective care and prevention of PIs necessitate a comprehensive plan from the entire healthcare system. RELEVANCE TO CLINICAL PRACTICE: This research fills a gap in the available data on the incidence, prevalence, and medical costs of PIs in Taiwan and Asia. PATIENT OR PUBLIC CONTRIBUTION: The findings can be used to help develop clinical guidelines for preventive education and treatment of PIs.

[Management of Patients With Kennedy Terminal Ulcer: Challenges and Best Practices].

Whether receiving acute, long-term, or home care, patients at the end of life may experience skin failure due to hemodynamic changes and insufficient perfusion of skin tissue. Skin failure begins as superficial ulcers that can quickly become full-thickness lesions, which are referred to as Kennedy terminal ulcers. Skin lesions commonly occur in the final 6 weeks of life and can occur even in the presence of a comprehensive care plan. The pathogenesis of Kennedy terminal ulcers is often misunderstood and these ulcers are commonly misdiagnosed as pressure injuries. This confusion may lead to aggressive care with subpar clinical outcomes that cause further psychological and emotional distress to patients and family members. Patients at the end of life must be provided care focused on their comfort rather than wound healing. To provide the highest quality of care to patients, four end-of-life strategies should be used, including: taking account of the preferences of patients and families, protecting the skin, describing the wound, and preserving a high quality of care. The terms, pathophysiological and clinical manifestations, and nursing treatments related to skin failure at the end of life described in the literature are introduced in this paper. Furthermore, monitoring indicators of nursing quality are provided.

[Challenges and Dilemmas of Providing Healthcare to Patients in Home Care Settings With Hard-to-Heal Wounds].

Hard-to-heal wounds (HHW) represent wound beds that are at high risk of stagnating during the inflammatory or proliferative phase because of various internal or external factors. A wound area reduction of less than 40% in 4 weeks is an indicator of HHW. With the acceleration of population aging, an increasing number of older adults are developing various chronic diseases with comorbidities. Although many older adults are affected by HHW, patients are regularly expected to recuperate at home or in long-term care institutions rather than in hospitals because of shortened hospitalization periods and changes in the medical insurance system. The provision of healthcare to patients with HHW in home settings is currently complicated by the lack of systematic nursing education on wound care, the lack of evidence-based guidelines for home wound care, and the inadequate wound care skills of nurses. HHW have major physical, psychological, and economic impacts on patients and their families and increase stress and frustration in nurses. Inappropriate wound care interventions increase medical expenditures and have multifaceted effects that are largely ignored by the medical care system. This phenomenon, which encompasses HHW, has been called a silent epidemic. In this paper, HHW are defined, the current status of home wound healing worldwide is analyzed, the relevant challenges and strategy implementations are discussed, and recommendations for the home care of HHW are provided.

[The Management of Itching in Burn Patients During the Rehabilitation Stage].

Pruritus, a distressing symptom that affects burn patients, not only interferes with activities of daily living but also causes disturbed sleep, which has been associated with anxiety, depression, and other types of negative moods. Furthermore, the uncontrolled scratching that often accompanies pruritus causes tissue damage and may damage or destroy the skin graft. In this paper, the authors first describe the definition and mechanism of pruritus and next use itching-assessment tools to identify the triggering factors. Finally, the authors propose a multifaceted approach to treating pruritus that includes using medication, topical emollients, massage therapy, skin moisture, relaxation techniques, and combined coping to relieve patient discomfort. The authors hope that this paper deepens and broadens the knowledge of health professionals on this issue and improves the quality of care that is available for burn patients who are in the rehabilitation stage.

[Major Burn Trauma Management and Nursing Care].

Major burn injury is one of the most serious and often life-threatening forms of trauma. Burn patients not only suffer from the physical, psychological, social and spiritual impacts of their injury but also experience considerable changes in health-related quality of life. This paper presents a review of the literature on the implications of previous research and clinical care guidelines related to major burn injuries in order to help clinical practice nurses use evidence-based care guidelines to respond to initial injury assessments, better manage the complex systemic response to these injuries, and provide specialist wound care, emotional support, and rehabilitation services.

Improving malignant fungating wound management among oncology nurses: a best practice implementation project.

INTRODUCTION: Appropriate malignant fungating wound (MFW) care is challenging for oncology nurses, leading to increased stress, compromised care quality, and poor patient outcomes. OBJECTIVE: This study aimed to address best practice barriers and develop evidence-based guidelines for MFW care. METHODS: This project was guided by the JBI Evidence Implementation Framework, which follows a seven-phase process. Both nurses' skills and patient charts were audited to determine compliance with best practices for comprehensive MFW assessment, wound photo records, use of validated wound assessment tools, appropriate wound care, and patient pain and satisfaction. Bandura's social learning theory was used to guide the development of an online education program and an objective structured clinical examination for skill improvement to prompt behavior change in nurses. A follow-up audit was conducted to measure improvements in knowledge, skills, and self-efficacy among nurses to validate the effectiveness of the intervention. RESULTS: The project resulted in improvements in all four evidence-based practice criteria: (1) comprehensive MFW assessments increased from 27% to 98%; (2) the inclusion of wound photos in medical records increased from 50% to 100%; (3) use of a validated wound assessment tool increased from 0% to 100%; and (4) appropriate interventions to manage wounds and maintain patients' quality of life increased from 50% to 90%. CONCLUSIONS: The project integrated a flexible education program, multidisciplinary collaboration, and leadership support to empower nurses to effectively manage MFWs. In addition, Bandura's social learning theory was used to influence nurses' behavior and bring about sustainable changes to organizational culture and practices. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A205.

[A comparison of the efficacy of different wound dressing management techniques in preventing pressure ulcers].

BACKGROUND: Although high-technology wound dressings are widely used in clinical care worldwide, no evidence or discussions have been published regarding the efficacy of these dressings in preventing pressure ulcers. PURPOSE: This study presents a repositioning of routine management combined with hydrocolloid dressing or foam dressing for pressure ulcer prevention. METHODS: We used a quasi-experimental design and recruited a convenience sample of 90 from a surgical intensive care unit (SICU) at a medical center in Hualien County, Taiwan. Participants were allocated randomly to one of three groups: repositioning of routine management, hydrocolloid dressing, and foam dressing. Study instruments included a pressure ulcer risk table (Braden scale) and the pressure ulcer classification system of the European Pressure Ulcer Advisory Panel. An independent sample t-test, ANOVA, and Mann-Whitney U test were used to verify research hypotheses. RESULTS: The repositioning of routine management group had the highest pressure ulcer incidence rate, followed by the hydrocolloid-dressing group. The foam-dressing group recorded no pressure ulcers. Pressure ulcer occurrence grades were primarily level 1 and 2. There was no significance difference in pressure ulcer occurrence time between the repositioning of routine-management group and the hydrocolloid-dressing group. Finally, there were significant differences (p < .05) among gender, hypertension history, and BMI regardless of pressure ulcer incidences. CONCLUSIONS: It is recommended that patients in high-risk groups in clinical settings adopt strategies including repositioning and regular visual skin examinations. Also, hydrocolloid or foam dressings may be used as appropriate to prevent sacral pressure ulcers.

Metabolic Syndrome-Related Knowledge, Attitudes, and Behavior among Indigenous Communities in Taiwan: A Cross-Sectional Study.

BACKGROUND: Metabolic syndrome is characterized by cardiovascular and chronic disease risk factors that cause health problems. Inequalities in medical resources and information present a challenge in this context. Indigenous communities may be unaware of their risk for metabolic syndrome. AIMS: This study explored factors associated with metabolic syndrome-related knowledge, attitudes, and behaviors among Taiwanese indigenous communities. METHODS: For this descriptive cross-sectional survey, we collected anthropometric data and used a self-administered questionnaire between 1 July 2016, to 31 July 2017, from a convenience sample of an indigenous tribe in eastern Taiwan. The response rate was 92%. RESULTS: The prevalence of metabolic syndrome was as high as 71%, and the average correct knowledge rate was 39.1%. The participants' self-management attitudes were mainly negative, and the self-management behaviors were low in this population. Stepwise regression analysis showed that knowledge, attitude, age, perception of physical condition, and body mass index, which accounted for 65% of the total variance, were the most predictive variables for self-management behaviors. CONCLUSIONS: This is the first study to report the relationship between metabolic syndrome knowledge, attitudes, and behaviors in an indigenous population. There is an urgent need to develop safety-based MetS health education programs that can provide access to the right information and enhance self-management approaches to lessen the growing burden of MetS in indigenous communities.

Symptom burden and quality of life in patients with malignant fungating wounds.

AIM: This study describes the relationship between symptoms and quality of life in patients with malignant fungating wounds. BACKGROUND: Malignant fungating wounds are complex wounds that can bleed, become malodorous due to infection and are painful causing physical and psychological distress. However, there is a lack of literature on the impact that such wounds can have on quality of life. METHODS: This was a descriptive, cross-sectional multi-centre study of patients with malignant fungating wounds. Participants were recruited from the palliative care, hospice, outpatient clinic and oncology units of three medical centres in Taiwan. Data were collected from February 2008 to August 2009. A structured questionnaire obtained socio-demographic information, medical details, wound assessment information and the Taiwanese version of the McGill quality of life questionnaire was administered by interview. RESULTS: McGill quality of life scores indicated that the participants had the lowest quality of life. The participant's age, dressing change frequency, pain, wound dressing comfort, wound symptom, bleeding and malodour had statistically significant negative correlations with quality of life. Multiple regression analysis showed that age, malodour, pain issues and psychological issues explained 87% of the total variance in quality of life. CONCLUSION: This study contributes to our understanding of the impact of malignant fungating wounds and how correct assessment and management is necessary to improve quality of life. Educational intervention research is needed for patients and caregivers in countries where this has not yet been performed. Further research should also identify whether nursing competence has a direct impact on quality of life.

[Prevention and management of pressure ulcers in critical patients].

The Taiwan Join Commission on Hospital Accreditation identified pressure ulcers as an important clinical care indicator in 2011. Pressure ulcers are a particularly critical medical care issue in hospital intensive care units. Pressure ulcers can influence patient physiology in terms of greater perceived pain, elevated infection and sepsis incidence, increased unplanned surgical treatments, and reduced activities of daily living (ADL). Pressure ulcers can also affect psychology through induced depression, stress, and anxiety. They can also increase patient and societal costs and prolong hospital stay length. This article explores the prevention and management of pressure ulcer in serious illness patients and introduces effective assessment and management techniques. We hope this article raises clinical nurse awareness of this critical issue and helps decrease the incidence of pressure ulcer-related complications in order to enhance overall quality of care.

Effectiveness of an E-Book App on the Knowledge, Attitudes and Confidence of Nurses to Prevent and Care for Pressure Injury.

AIMS: This study evaluates the effectiveness of an interactive E-book app training program in improving nurses' knowledge, attitudes, and confidence to prevent and care for pressure injury. DESIGN: Randomized experimental study. METHODS: Participants were recruited from a teaching hospital in Taiwan. The study was carried out between 20 March 2014 to 1 April 2016. In total, 164 participants were randomly assigned to a pressure injury E-book app training program (n = 86) or a conventional education program (n = 78) with a one-month follow-up. Outcome variables were levels of pressure injury knowledge, attitudes, and confidence of pressure injury care. RESULTS: Participants answered 51.96% of the pressure injury knowledge questions correctly before the intervention and 75.5% after the intervention. The pressure injury attitude score was slightly positive, with moderate confidence in pressure injury care. The knowledge, attitudes, and confidence of pressure injury care of the two groups in the pretest and posttest groups increased significantly. Analysis of covariance indicated that nurses in the pressure injury E-book app group had significantly greater improvement in knowledge, attitudes, and pressure injury care confidence as compared with the control group. CONCLUSION: The pressure injury E-book app interactive training program was effective in improving nurses' knowledge and attitudes toward pressure injury care and in enhancing their confidence in pressure injury care; therefore, this program has potential for nurses' in-service education in both Taiwan and worldwide. IMPACT: E-book apps allow individuals to control the time and place of learning. Direct observation of procedural skills can provide feedback to trainees on techniques to ensure learning effectiveness and pressure injury care quality.

Effects of Group Music Intervention on Depression for Elderly People in Nursing Homes.

Depression is the most common mental problem among the elderly, especially in long-term care facilities. The purpose of the present study was to examine the effects of group music intervention on depression for elderly people in nursing homes. Methods: A randomized control trial consisting of sixty-three elderly participants randomly and blindly assigned to a music group or control group was utilized. The music group received 20 sessions of group music intervention (two 30-min sessions per week for 10 weeks), and the control group received usual care with no music intervention. The Geriatric Depression Scale-Short Form (GDS-SF) and salivary cortisol at baseline, 5 weeks, and 10 weeks were collected for analysis. Results of the GEEs (generalized estimating equations) analysis indicated that after 20 sessions for 10 weeks of group music intervention, the groups showed a statistically significant difference in depression at 5 weeks and 10 weeks. There was no significant difference in the salivary cortisol concentration between the two groups. The results show that the group music intervention may effectively reduce the depression scores for elderly people in nursing homes. Conclusion: The group music intervention has positive effects on depression.

Multimedia education programme for patients with a stoma: effectiveness evaluation.

AIM: This paper is a report of an evaluation of the effectiveness of a multimedia education program in relation to stoma knowledge, self-care attitudes and behaviour with patients with a stoma in the postoperative period. BACKGROUND: Multimedia education programmes not only give patients with useful information in the absence of health professionals, but can also augment information given in traditional clinical practice. However, the literature on the effectiveness of different approaches to stoma education is limited. METHOD: A randomized experimental study design was used. Participants were recruited from a surgical unit in a large hospital in Taiwan. A total of 102 patients with a stoma were randomly assigned to either the multimedia education programme (n=46) or a conventional stoma education programme (n=56) with a follow-up of 1 week. Outcome variables measured were levels of self-care knowledge, attitudes towards self-care and self-care behaviour. FINDINGS: Patients who received the multimedia education programme improved their overall self-care knowledge, attitudes and behaviour statistically significantly when compared with those who received the conventional stoma education programme. CONCLUSION: Although further, longer-term follow-up will be useful, this study demonstrates that multimedia packages can enhance patient involvement in their stoma care and can augment stoma education - particularly in resource challenged healthcare environments.

Prevalence and Medical Resource of Patients with Diabetic Foot Ulcer: A Nationwide Population-Based Retrospective Cohort Study for 2001-2015 in Taiwan.

Diabetic foot ulcer (DFU) is one of the common complications of diabetes. DFU can cause a huge medical and financial burden due to infections, compromise the quality of life, and increase the mortality rate in patients. However, the consumption of medical resources for DFU is rarely mentioned. A retrospective cohort study was performed. Data were obtained from the National Health Insurance Research Database of Taiwan, and the prevalence and medical utilization data for DFU in 2001-2015 were extracted, followed by the analysis for high-risk populations. Between 2001 and 2015, there were 7511 new DFU patients. A higher proportion in these patients was male, elderly with a low education level, and low income. Between 2001 and 2015, the prevalence of DFU was 0.5-0.8%, and the number of DFU patients showed stable growth. Every year, 12.6-19.3% and 1.2-7.0% of patients underwent debridement and amputation, respectively. The hospitalization fees increased year on year. Our study showed that the DFU prevalence increased year on year, and the DFU medical expenditure increased. DFU tends to occur in males, patients with low socioeconomic status, low education level, those with multiple comorbidities, and old age. Therefore, DFU care and prevention require the entire healthcare system to jointly formulate a prevention plan.

The effectiveness of multimedia learning education programs on knowledge, anxiety and pressure garment compliance in patients undergoing burns rehabilitation in Taiwan: an experimental study.

AIM: This study examined the effectiveness of multimedia learning education programmes (MLEPs) on knowledge, anxiety and pressure garment compliance behaviour of burn patients. BACKGROUND: MLEPs are increasingly suggested as education methods that can be used by health professionals in daily practice. A systematic review of the effectiveness of computer-based education demonstrates its acceptability to patients. However, few studies have empirically tested this approach. DESIGN: Experimental study. METHODS: An experimental study was conducted at a burn centre of a medical centre in Taipei, Taiwan. Participants were randomly assigned to either experimental (n = 28) or control groups (n = 30). Both groups were given pre-tests and post-tests to measure their knowledge, anxiety and pressure garment compliance behaviour. RESULTS: At two weeks, the results of this study showed that the MLEP had 'statistically' significantly improved patients' burn knowledge, reduced individual anxiety and enhanced pressure garment compliance behaviour. CONCLUSION: This controlled study demonstrated that a two week MLEP can be a useful intervention to improve care compliance and reduce anxiety in patients undergoing burns rehabilitation period. RELEVANCE TO CLINICAL PRACTICE: Burn injury patients undergoing rehabilitation are likely to benefit from multimedia learning education intervention programmes. More comprehensive health economic evaluation needs to be undertaken. Further studies exploring a longer term follow-up are also required.

A cost-effectiveness analysis of a multimedia learning education program for stoma patients.

STUDY AIMS: The purpose of this study was to compare the costs and effectiveness of enterostomal education using a multimedia learning education program (MLEP) and a conventional education service program (CESP). BACKGROUND: Multimedia health education programs not only provide patients with useful information in the absence of health professionals, but can also augment information provided in traditional clinical practice. However, the literature on the cost-effectiveness of different approaches to stoma education is limited. DESIGN: This study used a randomised experimental design. METHODS: A total of 54 stoma patients were randomly assigned to MLEP or CESP nursing care with a follow-up of one week. Effectiveness measures were knowledge of self-care (KSC), attitude of self-care (ASC) and behavior of self-care (BSC). The costs measures for each patient were: health care costs, MLEP cost and family costs. RESULTS: Subjects in the MLEP group demonstrated significantly better outcomes in the effectiveness measures of KSC, ASC and BSC. Additionally, the total social costs for each MLEP patient and CESP patient were US$7396·90 and US$8570·54, respectively. The cost-effectiveness ratios in these two groups showed that the MLEP model was better than the CESP model after one intervention cycle. In addition, the Incremental Cost Effectiveness Ratio was -20·99. CONCLUSION: This research provides useful information for those who would like to improve the self-care capacity of stoma patients. Due to the better cost-effectiveness ratio of MLEP, hospital policy-makers may consider these results when choosing to allocate resources and develop care and educational interventions. RELEVANCE TO CLINICAL PRACTICE: This study provides a cost effective way of addressing stoma care in the post-operative period that could be usefully transferred to stoma care settings internationally.

The effectiveness of silver-releasing dressings in the management of non-healing chronic wounds: a meta-analysis.

AIM: The purpose of this study was to examine the efficacy of silver-releasing dressings in the management of non-healing chronic wounds. BACKGROUND: Non-healing chronic wounds often have a negative physical impact on patients and place a financial burden on healthcare systems. Silver dressings are wound products designed to control infection and provide a wound environment conducive to healing. However, validation of the clinical efficacy of these dressings is lacking. DESIGN: Systematic review and meta-analysis. METHODS: A systematic search of the major electronic databases PubMed, CINAHL, Cochrane, MEDLINE, British Nursing Index, EBSCO, OCLC and Proquest between 1950-June 2007 was conducted. Hand searches of selected periodicals, textbooks and checking reference lists and contacting experts was also performed. RESULTS: Eight studies were selected from a potentially relevant 1957 references screened. Analysis incorporated data from 1399 participants in the eight randomised control trials. We found that silver dressings significantly improved wound healing (CI(95): 0.16-0.39, p < 0.001), reduced odour (CI(95): 0.24-0.52, p < 0.001) and pain-related symptoms (CI(95): 0.18-0.47, p < 0.001), decreased wound exudates (CI(95): 0.17-0.44, p < 0.001) and had a prolonged dressing wear time (CI(95): 0.19-0.48, p = 0.028) when compared with alternative wound management approaches. An analysis of sensitivity in these studies by subgroup analysis generally supported these associations. Furthermore, studies indicated an improvement in quality of life (CI(95): 0.04-0.33, p = 0.013) using silver dressings in wound management with no associated severe adverse events. CONCLUSION: This meta-analysis confirms the effectiveness of silver dressings in wound healing and improving patients' quality of life. However, it also highlights the need for additional well-designed randomised controlled trials to evaluate the effectiveness of silver-related dressings further. RELEVANCE TO CLINICAL PRACTICE: The results of this study provide objective data on the effectiveness of silver-related dressing when applied to non-healing chronic wounds.

An Exploration of Factors Related to Quality of Life in Indonesian Care Workers in Home-Based Care Settings.

BACKGROUND: Indonesians constituted 79% of foreign care workers for long-term care in Taiwan in 2015. Therefore, it is crucial to explore the effect of work stress and quality of life (QoL) on this population. PURPOSE: This study aims to explore stress levels, social support requirements, and perceived QoL among Indonesian care workers (ICWs) who work in home care settings. METHODS: A cross-sectional design was used. Data were collected between 2014 and 2016 from a convenience sample of ICWs working in eastern Taiwan using a self-administered questionnaire that comprised the Stress Perception Scale (SPS), Social Support Scale (SSS), and World Health Organization Quality of Life-Brief scale. One hundred fifty-seven valid questionnaires were collected. The response rate was 80.51%. Data were analyzed using descriptive statistics, one-way analysis of variance, Pearson's correlation coefficient, and multiple regression analysis. RESULTS: The results found that the average SPS of the sample was 70.50, with low QoL scores and requirements for more social support. In addition, significant and positive correlations were found between QoL and SPS, SSS, duration of patient care, and hours of care per week. Stepwise regression analysis showed that the most predictive variables for QoL were time spent caring, preservice training, psychological stress, and emotional support, which together accounted for 60.9% of the total variance. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: This study facilitated understanding of the stress on ICWs and the impact of social support on their QoL. The findings suggest that new immigrants in Taiwan should be introduced to foreign care workers or nursing attendants. Moreover, long-term-care-related teachers should work with home care institutions or agencies to develop a teaching model for innovative care skills to relieve the perceived stress of ICWs.

Experiences of living with a malignant fungating wound: a qualitative study.

AIMS AND OBJECTIVES: The purpose of this study was to explore the experience of cancer patients living with a malignant fungating wounds. BACKGROUND: Malignant fungating wounds are caused by cancerous cells invading skin tissue. These wounds can then bleed, become malodorous and painful causing physical and psychological distress. However, little is know about how individuals experience these lesions. DESIGN: Qualitative. METHODS: Ten in-depth interviews were conducted with patients in one medical teaching centre in Taiwan. Data were subject to a thematic analysis informed by elements of grounded theory. RESULTS: Five key themes demonstrated an emerging model that offers an insight into how patients experience their wound. Firstly, 'Declining physical well-being' refers to the initial impact of the wound, this is linked to two further themes; 'Wound related stigma' and the 'Need for expert help'. Another theme; 'Strategies in wound management' describes the initial, ineffective attempts by participants to manage their wound and the impact of professional help around wound management. This was linked to a fifth theme; 'Living positively with the wound' that reflected how patients adjusted to the presence of the wound -- significantly influenced by the wound care they received. CONCLUSION: This study contributes to the understanding we have of how patients experience living with such wounds. It sets out the clear need for early use of wound specialists as part of the multi-disciplinary oncology team. RELEVANCE TO CLINICAL PRACTICE: The results of this study provides a description of patient experiences that can help to guide nursing practice as well as an understanding of what a malignant fungating wound means to cancer patients and how it influences their lives.