Pressure ulcer risk assessment in the ICU. Is it time for a more objective measure?

BACKGROUND: The Braden scale, one of the most widely used risk assessment tools is often criticized when used in the Intensive Care Unit. Most patients in the Intensive Care Unit are at risk of pressure ulcer development meaning that the Braden score will usually indicate high risk for these patients. This study set out to determine the correlation between Sub-Epidermal Moisture measurements and Braden scores among Intensive Care Unit patients. METHODS: This study employed an observational research design. Braden score was assessed on all study days (1-5), in addition to visual skin assessment and Sub-Epidermal Moisture measurements at the sacrum and heels. Sub-Epidermal Moisture measurements were categorised as low (<0.5), borderline abnormal (≥0.5), and high (≥0.8). Correlation was assessed between Sub-Epidermal Moisture levels and Braden scores. RESULTS: A total of 53 participants were recruited. The median (interquartile range) baseline Braden score was 9 (9-10) and 81 % (n = 43) of participants were at very high/high risk of pressure ulcer development. Braden scores remained relatively constant over time with little fluctuation in scores. 19 % (n = 10) of patients had normal (<0.5) Sub-Epidermal Moisture delta measurements on enrolment, and all developed abnormal measurements by day 2. There were no significant correlations between Braden scores and Sub-Epidermal Moisture measurements. CONCLUSION: Although this was not its original intention, a missing link with the Braden scale is that it does not provide information on how patients are responding to the adverse effects of pressure and shear forces. Furthermore, in patients who are critically unwell, most patients are classified as being "at risk" of pressure ulcer development. Therefore, an objective measure of how patients are responding to pressure and shear forces at different anatomical areas is needed. IMPLICATIONS TO CLINICAL PRACTICE: Sub-Epidermal Moisture measurements can offer more information, not only on identifying those who are at risk, but also how those patients are tolerating this risk at different anatomical sites.

Assessing the healthcare costs associated with venous leg ulcer compression bandages - A scoping review.

AIM: To determine the monetary costs identified in economic evaluations of treatment with compression bandages among adults with venous leg ulcers (VLU). METHOD: A scoping review of existing publications was conducted in February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. RESULTS: Ten studies met the inclusion criteria. To place the costs of treatment into context, these are reported in conjunction with the healing rates. Three comparisons were made: 1.4 layer compression versus no compression (3 studies). One study reported that 4 layer compression was more expensive than usual care (£804.03 vs £681.04, respectively), while the 2 other studies reported the converse (£145 vs £162, respectively) and all costs (£116.87 vs £240.28 respectively). Within the three studies, the odds of healing were statistically significantly greater with 4 layer bandaging (OR: 2.20; 95% CI: 1.54-3.15; p = 0.001).; 2.4 layer compression versus other compression (6 studies). For the three studies reporting the mean costs per patient associated with treatment (bandages alone), over the treatment period, analysis identified a mean difference (MD) in costs for 4 layer vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) of -41.60 (95% CI: 91.40 to 8.20; p = 0.10). The OR of healing for 4 layer compression vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 0.70 (95% CI: 0.57-0.85; p = 0.004). For 4 layer vs comparator 2 (2 layer compression) the MD is: 14.00 (95% CI: 53.66 to -25.66; p < 0.49). The OR of healing for 4 layer compression vs comparator 2 (2 layer compression) is: 3.26 (95% CI: 2.54-4.18; p < 0.00001). For comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) vs comparator 2 (2 layer compression) the MD in costs is: 55.60 (95% CI: 95.26 to -15.94; p = 0.006). The OR of healing with Comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 5.03 (95% CI:4.10-6.17; p < 0.00001). Three studies presented the mean annual costs per patient associated with treatment (all costs). The MD is 172 (150-194; p = 0.401), indicating no statistically significant difference in costs between the groups. All studies showed faster healing rates in the 4 layer study groups. 3. Compression wrap versus inelastic bandage (one study). Compression wrap was less expensive than inelastic bandage (£201 vs £335, respectively) with more wounds healing in the compression wrap group (78.8%, n = 26/33; 69.7%, n = 23/33). CONCLUSION: The results for the analysis of costs varied across the included studies. As with the primary outcome, the results indicated that the costs of compression therapy are inconsistent. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Health-related quality of life and assessment in patients with lower limb lymphoedema: a systematic review.

OBJECTIVE: To determine the impact of lower limb lymphoedema (LLL) on health-related quality of life (HRQoL), and to identify the methodologies used to assess HRQoL and their adherence to the World Health Organization (WHO)-recommended HRQoL dimensions. METHOD: A systematic review was used following the PRISMA guidance. Studies were eligible if they assessed HRQoL in adult patients with LLL. The search was conducted between September 2019 and February 2020 using CINAHL, PubMed, Scopus, EMBASE and the Cochrane Library database. Data were placed onto a pre-developed data extraction table and analysed using a narrative synthesis. Evidence-based Librarianship (EBL) was used for quality appraisal. RESULTS: A total of 18 studies were identified, among which 10 were cross-sectional and eight were longitudinal studies. Twelve HRQoL questionnaires were identified and the Lymphoedema Quality of Life tool (LYMQoL) was the most commonly used. All of the studies except one had an EBL validity score of ≥75%. Although LLL causes a considerable impairment in HRQoL, the findings varied across the studies. All the studies considered at least four of the six WHO recommended dimensions, with none considering the spirituality dimension. Furthermore, physical functioning and wellbeing were discovered to be the worst affected HRQoL dimensions. CONCLUSION: LLL adversely affects physical function, wellbeing and thus the HRQoL. The LYMQoL is the most commonly used questionnaire; despite this, all elements of the WHO recommendations were not captured in the included studies. However, accurate information on HRQoL indicating the impact of the disease on survivors' lives and complete wellbeing is needed to inform evidence-based decision-making. Furthermore, having a universally accepted, disease-specific methodology will facilitate comparison and contrasting of HRQoL in patients with LLL. DECLARATION OF INTEREST: The authors have no conflicts of interest.

Costing pressure ulcer care in an Irish acute care setting: a feasibility study.

OBJECTIVE: To test the feasibility of using a standardised data collection tool to estimate the cost of stage 2-4 pressure ulcer (PU) care within an acute care setting. METHOD: Data on resource use and cost were obtained through a retrospective survey of nursing and medical notes collecting cost data for individual patients who received care for stage 2-4 PUs. RESULTS: Data for 20 patients (12 male/8 female) were analysed. The average patient age was 69 years (range: 37-95 years). Of this sample, seven patients had hospital-acquired PUs (HAPUs) and 14 patients had community-acquired PUs (CAPU) (one patient had both-in different anatomical areas). Over half of the total sample (55%; n=11) had a stage 2 PU. The average length of stay was 31.8 days (range: 5-119 days). Most of the patients (70%; n=14) had a CAPU. The average cost per patient with PU care was €878 (range: €39-2393). The mean cost for patients with a HAPU was €866 (SD: €1313) versus €911 (SD: €567) for patients with a CAPU. The majority of the cost related to equipment and staff time for treatment. CONCLUSION: Overall, the application of the standardised data collection tool to obtain cost data from retrospective inspection of nursing and medical notes is feasible. The cost of PU care in this sample was high, indicating that these wounds may impose a substantial burden on health systems. The costs varied greatly between patients in the sample, reflecting the complexity of PU care. Furthermore, given that costs increased with the higher PU stages, there is a potential to reduce costs by preventing the development of higher stage PUs. Larger-scale studies are required to understand the cost variation and full economic impact of PU care. DECLARATION OF INTEREST: The authors have no conflicts of interest.

The economic impact of pressure ulcers among patients in intensive care units. A systematic review.

BACKGROUND: The incidence and prevalence of pressure ulcers in critically ill patients in intensive care units (ICUs) remain high, despite the wealth of knowledge on appropriate prevention strategies currently available. METHODS: The primary objective of this systematic review was to examine the economic impact of pressure ulcers (PU) among adult intensive care patients. A systematic review was undertaken, and the following databases were searched; Medline, Embase, CINAHL, and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to formulate the review. Quality appraisal was undertaken using the Consensus on Health Economic Criteria (CHEC)-list. Data were extracted using a pre-designed extraction tool, and a narrative analysis was undertaken. RESULTS: Seven studies met the inclusion criteria. Five reported costs associated with the prevention of pressure ulcers and three explored costs of treatment strategies. Four main PU prevention cost items were identified: support surfaces, dressing materials, staff costs, and costs associated with mobilisation. Seven main PU treatment cost items were reported: dressing materials, support surfaces, drugs, surgery, lab tests, imaging, additional stays and nursing care. The overall validities of the studies varied between 37 and 79%, meaning that there is potential for bias within all the included studies. CONCLUSION: There was a significant difference in the cost of PU prevention and treatment strategies between studies. This is problematic as it becomes difficult to accurately evaluate costs from the existing literature, thereby inhibiting the usefulness of the data to inform practice. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Sub-epidermal moisture measurement: an evidence-based approach to the assessment for early evidence of pressure ulcer presence.

This paper aims to discuss the literature pertaining to early pressure-shear induced tissue damage detection, with emphasis on sub-epidermal moisture measurement (SEM). The current method for pressure detection is visual skin assessment (VSA); however, this method is fraught with challenges. Advances in early detection of pressure ulcers are reported in the literature and mainly involve measuring inflammation markers on weight-bearing anatomical areas in order to capture the first signs of tissue damage. One novel technique currently in use is SEM measurement. This biophysical marker is the product of plasma that leaks as a response to local inflammation arising due to pressure-shear induced damage over bony prominences. The early detection of tissue damage is beneficial in two different ways. First, it enables early intervention when the damage is still microscopic and reversible and, therefore, has the potential to prevent further aggravation of healthy surrounding tissue. This arises by avoiding the causation of the problem and stopping the knock-on effect of inflammation, especially when the rapid pressure ulceration pathway of deformation is in place. Second, when the slow ischaemic-reperfusion related mechanism is undergoing, cell death can be avoided when the problem is identified before the cell reaches the "death threshold," completely averting a pressure ulcer.

Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency.

OBJECTIVE: Pressure ulcers (PUs) involve the destruction of skin and underlying tissue due to prolonged pressure and shear forces. These ulcers are painful and significantly reduce a person's quality of life. PUs are also expensive to manage and impact negatively on the achievement of cost-effective, efficient care delivery. METHOD: Prone positioning is a postural therapy that aims to enhance respiratory function through increasing oxygenation levels. In contemporary clinical practice, ventilation in the prone position is indicated for patients with severe acute respiratory distress syndrome. However, despite its advantages in terms of respiratory function, several studies have examined complications of prone position ventilation and have identified PUs (facial PUs as well as PUs on other weight-bearing areas of the body) as a frequent complication in patients who are already in a precarious medical situation. International data suggest that up to 57% of patients nursed in the prone position develop a PU. The aim of this clinical review is to identify and review evidence-based recommendations developed to facilitate the selection and application of preventive interventions aimed at reducing PU development in patients ventilated in the prone position. Given the current COVID-19 crisis, this review is timely as intensive care unit (ICU) patients with COVID-19 require ventilation in the prone position at a level that is disproportionate to the general intensive care population. Up to 28% of patients admitted to the ICU with confirmed infection due to severe COVID-19 are cared for in the prone position. The scope of this review is limited to adult individuals only. RESULTS: The skin assessment should be undertaken before proning and following positioning the patient back into the supine position. Although it is essential to keep the skin clean and moisturised, using pH-balanced cleansers, there is inconsistency in terms of the evidence to support the type of moisturiser. Use of positioning devices in addition to repositioning is recommended to offload pressure points on the face and body. Further, using dressings such as hydrocolloids, transparent film and silicone may be of benefit in decreasing facial skin breakdown. CONCLUSION: Given the importance of PU prevention in this cohort of patients, adopting a focused prevention strategy, including skin assessment and care, offloading and pressure redistribution, and dressings for prevention may contribute to a reduction in the incidence and prevalence of these largely preventable wounds.

Methodological approaches for assessing the cost of diabetic foot ulcers: a systematic literature review.

OBJECTIVE: To evaluate the methodological approaches used to assess the cost consequences of diabetic foot ulcers (DFUs) in published scientific papers. METHOD: A systematic literature search was conducted in PubMed, Embase, Scopus, Web of Science and CINAHL. English language papers reporting on the cost of DFUs were identified. Additionally, bibliographies were inspected to identify other relevant cost studies. Following the PRISMA guidance, the review identified the study design, epidemiological approach, analytical perspective and data collection approach in each of the included studies. RESULTS: Relatively few studies of the cost consequences of DFUs were found (n=27). Most studies were conducted in Western countries with only five studies from countries in Asia and Africa. The identified studies used different study designs, epidemiological approaches, data collection strategies, and data sources, which in turn made a systematic comparison of cost estimates difficult. Detailed descriptions of the applied costing method and other methodological aspects were often limited or absent. Many studies only reported costs from a health-care payer's perspective and disregarded the costs to patients, their families and wider society. CONCLUSION: The costs of DFUs have been assessed using a wide range of different methodological approaches often restricted to the healthcare payer's perspective. Therefore, the cost analyses may fail to consider the true societal costs of DFUs.

Risk assessment tools for the prevention of pressure ulcers.

BACKGROUND: Use of pressure ulcer risk assessment tools or scales is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to provide a summary of the evidence pertaining to pressure ulcer risk assessment in clinical practice, and this is the third update of this review. OBJECTIVES: To assess whether using structured and systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers. SEARCH METHODS: In February 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of structured and systematic pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment and GRADE assessment of the certainty of evidence. MAIN RESULTS: We included two studies in this review (1,487 participants). We identified no new trials for this latest update.Both studies were undertaken in acute-care hospitals. In one study, patients were eligible if they had a Braden score of 18 or less. In the second study all admitted patients were eligible for inclusion, once they were expected to have a hospital stay of more than three days and they had been in hospital for no more than 24 hours before baseline assessment took place. In the first study, most of the participants were medical patients; no information on age or gender distribution was provided. In the second study, 50.3% (619) of the participants were male, with a mean age of 62.6 years (standard deviation (SD): 19.3), and 15.4% (190) were admitted to oncology wards.The two included studies were three-armed studies. In the first study the three groups were: Braden risk assessment tool and training (n = 74), clinical judgement and training (n = 76) and clinical judgement alone (n = 106); follow-up was eight weeks. In the second study the three groups were: Waterlow risk assessment tool (n = 411), clinical judgement (n = 410) and Ramstadius risk assessment tool (n = 410); follow-up was four days. Both studies reported the primary outcome of pressure ulcer incidence and one study also reported the secondary outcome, severity of new pressure ulcers.We are uncertain whether use of the Braden risk assessment tool and training makes any difference to pressure ulcer incidence, compared to risk assessment using clinical judgement and training (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.53 to 1.77; 150 participants), or compared to risk assessment using clinical judgement alone (RR 1.43, 95% CI 0.77 to 2.68; 180 participants). We assessed the certainty of the evidence as very low (downgraded twice for study limitations and twice for imprecision).Risk assessment using the Waterlow tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 1.10, 95% CI 0.68 to 1.81; 821 participants; stage 1 pressure ulcers: RR 1.05, 95% CI 0.58 to 1.90; 821 participants; stage 2 pressure ulcers: RR 1.25, 95% CI 0.50 to 3.13; 821 participants), or risk assessment using the Ramstadius tool (pressure ulcers of all stages: RR 1.41, 95% CI 0.83 to 2.39; 821 participants; stage 1 pressure ulcers: RR 1.16, 95% CI 0.63 to 2.15; 821 participants; stage 2 pressure ulcers: RR 2.49, 95% CI 0.79 to 7.89; 821 participants). Similarily, risk assessment using the Ramstadius tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 0.79, 95% CI 0.46 to 1.35; 820 participants; stage 1 pressure ulcers: RR 0.90, 95% CI 0.48 to 1.68; 820 participants; stage 2 pressure ulcers: RR 0.50, 95% CI 0.15 to 1.65; 820 participants). We assessed the certainty of the evidence as low (downgraded once for study limitations and once for imprecision).The studies did not report the secondary outcomes of time to ulcer development, or pressure ulcer prevalence. AUTHORS' CONCLUSIONS: We identified two studies which evaluated the effect of risk assessment on pressure ulcer incidence. Based on evidence from one study, we are uncertain whether risk assessment using the Braden tool makes any difference to pressure ulcer incidence, compared with training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone. Risk assessment using the Waterlow tool, or the Ramstadius tool may make little or no difference to pressure ulcer incidence, or severity, compared with clinical judgement. The low, or very low certainty of evidence available from the included studies is not reliable enough to suggest that the use of structured and systematic pressure ulcer risk assessment tools reduces the incidence, or severity of pressure ulcers.

Analysis of Emergency Health Care Workforce and Service Readiness for a Mass Casualty Event in the Republic of Ireland.

OBJECTIVE: Ultimately, a country's capacity for a large-scale major emergency response will be directly related to the competence of its health care provider (HCP) workforce and communication between emergency responders and hospitals. The purpose of this study was to assess HCP preparedness and service readiness for a major emergency involving mass casualties (mass casualty event or MCE) in Ireland. METHODS: A cross-sectional study using a 53-item survey was administered to a purposive sample of emergency responders and HCPs in the Republic of Ireland. Data collection was achieved using the Qualtrics® Research Suite. Descriptive statistics and appropriate tests of comparison between professional disciplines were conducted using Stata 13. RESULTS: A total of 385 respondents, registered nurses (43.4%), paramedics (37.9%), medical doctors (10.1%), and administrators/managers (8.6%), participated in the study. In general, a level of knowledge of MCEs and knowledge of clinical response activities and self-assessed clinical competence varied drastically across many aspects of the survey. Knowledge and confidence also varied across professional disciplines (P<0.05) with nurses, in general, reporting the least knowledge and/or confidence. CONCLUSIONS: The results demonstrate that serious deficits exist in HCP knowledge, skills, and self-perceived abilities to participate in a large-scale MCE. Results also suggest a poor knowledge base of existing major emergency response plans. (Disaster Med Public Health Preparedness. 2019;13:243-255).

Organisation of health services for preventing and treating pressure ulcers.

BACKGROUND: Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment. OBJECTIVES: To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers. SEARCH METHODS: In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence. MAIN RESULTS: The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low. AUTHORS' CONCLUSIONS: Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

The relationship between nurses assessment of early pressure ulcer damage and sub epidermal moisture measurement: A prospective explorative study.

AIM: To explore the relationship between nurses' visual assessment of early pressure ulceration and assessment using sub epidermal moisture measurement (a measure of skin and tissue water). MATERIALS AND METHODS: A descriptive prospective observational study design was employed. Following ethical approval and written informed consent, data were collected daily, for four weeks, from at risk patients within an acute care facility in Ireland. Data included nurses documented assessment of the patient's skin condition and researcher led sub epidermal moisture measurement, over the sacrum and both heels. RESULTS: A total of 47 patients were included, 38.3% (n = 18) were male and 61.5% (n = 29) were female, with a mean age of 74.7 years. Nineteen patients (40%) developed 21 Stage 1 pressure ulcers and all of these had sustained elevated sub epidermal moisture (SEM) levels before visual signs of damage became evident indicating 100% sensitivity of SEM readings in predicting pressure ulceration. Specificity was 83% with the majority of false positives having insufficient follow-up time. Furthermore a medium correlation between nurses' visual skin assessment (the current gold standard in pressure ulcer detection) and SEM findings (r = .47; p = 0.001) was identified. The mean number of days for nurses to detect this damage was 5.5 (±2,5; max 11, min 2), whereas the mean number of days that it took SEM measurement to detect damage was 1.5 (±1.4; max 7, min 1). SEM measurement identified early damage, on average, 4 days sooner than nurses' assessment. CONCLUSION: Given that pressure ulcers develop from within the deeper tissues, knowing that early pressure ulcer damage is present can facilitate heightening of prevention strategies to avoid extension. This is of importance in clinical practice as the earlier that pressure ulcers can be detected; the earlier interventions can be implemented to prevent further extension, avoiding their associated morbidity and mortality.

Exploring the prevalence and management of wounds in an urban area in Ireland.

AIM: This study explores the prevalence and management of wounds within an urban setting in Ireland. METHOD: It employs a cross-sectional survey design, using a predesigned, validated data-collection instrument. FINDINGS: The point prevalence of wounds was 3.7% (n=445), with surgical wounds being the most prevalent (43%; n=189). Wound care was provided across a wide variety of clinical settings, with the majority of patients (60%; n=271) managed in the acute care setting. Most dressings were changed 2-3 times a week (60%; n=271). The mean dressing time was 15 minutes (SD: 12.4 minutes), varying from 2 minutes to 90 minutes. The mean nurse travel time was 3 minutes (SD: 6.5 minutes), varying from 0-60 minutes. Among participants managed using silver and iodine dressings, 53% (n=10, silver) and 78% (n=50, iodine) were prescribed for wounds described as being not infected. Alginate dressings were used incorrectly in 75% of cases, foam dressings in 63% of cases and Hydrofiber dressings in 63% of cases. CONCLUSION: Wound management within the explored geographical area is an important clinical intervention. This study identified areas of practice that need to be addressed, primarily those related to the topical management of the wound and use of offloading. The data has been used to inform practice, education, and further research in this important clinical specialty.

The prevalence, aetiology and management of wounds in a community care area in Ireland.

This study aimed to establish the prevalence and aetiology of wounds, allowing an insight into the management of wound care, the use of dressings and the nursing time allocated to the provision of wound care in a community setting in Ireland. A cross-sectional survey was used, with data collected on all clients in the community who received treatment from public health nurses or community registered general nurses for wound care over a 1-week period in April 2013. A 98.9% response rate was realised, and 188 people were identified as having wounds, equating to a crude prevalence of 5% of the active community nursing caseload. A total of 60% (n=112) had leg ulcers, 22% (n=42) had pressure ulcers, 16% (n=30) had an acute wound (surgical or traumatic wounds), 1% (n=2) had a diabetic foot wound and a further 1% (n=2) had wounds of other aetiologies. The mean duration of wounds was 5.41 months. A total of 18% of wounds were identified as infected; however, 60% (n=112) of wounds had antimicrobial products in use as either a primary or secondary dressing. The study established that there is a significant prevalence of wounds in this community care area. There was absence of a clinical diagnosis in many cases, and evidence of inappropriate dressing use, risking an increase in costs and a decrease in good clinical outcomes. It also highlighted the importance of ongoing education and auditing in the provision of wound care.

Risk assessment tools for the prevention of pressure ulcers.

BACKGROUND: Use of pressure ulcer risk assessment tools or scales is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Indeed, use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to provide a summary of the evidence pertaining to pressure ulcer risk assessment in clinical practice. OBJECTIVES: To determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. SEARCH METHODS: In December 2013, for this second update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of structured, systematic, pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility, obtained full versions of potentially relevant studies and screened these against the inclusion criteria. MAIN RESULTS: We included two studies in this review. One small, cluster randomised study found no statistical difference in pressure ulcer incidence in patients who were assessed by nurses using the Braden risk assessment tool (n=74) compared with patients assessed by nurses who had receiving training and then used unstructured risk assessment (n=76) (RR 0.97, 95% CI 0.53 to 1.77) and those patients assessed by nurses using unstructured risk assessment alone (n=106) (RR 1.43, 95% CI 0.77 to 2.68). The second study was a large single blind randomised controlled study which compared the effect of risk assessment on pressure ulcer incidence using the Waterlow risk assessment tool (n=411), the Ramstadius risk screening tool (n=420) and no formal risk assessment (n=420). There was no statistical difference in pressure ulcer incidence between the three groups (Waterlow 7.5% (n=31); Ramstadius 5.4% (n=22); clinical judgement 6.8% (n=28) (RR 1.10, 95% CI 0.68 to 1.81; Waterlow vs no formal risk assessment), (RR 0.79, 95% CI 0.46 to 1.35; Ramstadius vs no formal risk assessment), (RR 1.44, 95% CI 0.85 to 2.44; Waterlow vs Ramstadius). AUTHORS' CONCLUSIONS: Two studies were identified which evaluated the effect of risk assessment on patient outcomes; In one study, there was no statistically significant difference in pressure ulcer incidence between people who were assessed using the Braden risk assessment tool compared with those receiving unstructured risk assessment. Methodological limitations of this study prevent firm conclusions being drawn. However, a further high quality RCT identified no statistical differences in pressure ulcer incidence when people were assessed using either the Waterlow risk assessment tool, the Ramstadius risk assessment tool, or using clinical judgement alone. There is no reliable evidence to suggest that the use of structured, systematic pressure ulcer risk assessment tools reduces the incidence of pressure ulcers.

An economic analysis of repositioning for the prevention of pressure ulcers.

AIMS AND OBJECTIVES: To compare pressure ulcer incidence and costs associated with repositioning older individuals in long-term care using two different repositioning regimes. BACKGROUND: Repositioning has not always been integrated into pressure ulcer preventative methods, with arguments that it is an expensive procedure in terms of personnel and time. DESIGN: Participants were randomly allocated to the experimental group (n = 99; repositioned every 3 hours, using the 30° tilt) and the control group (n = 114 standard care, repositioned every 6 hours, using the 90° lateral rotation). The analysis explored the incidence of pressure ulcer development and the cost difference between the two repositioning schedules, over a 4-week period. RESULTS: The mean daily nurse time for repositioning was 18·5 minutes (experimental) and 24·5 minutes (control). Nurse time cost per patient over the study period was €206·6 (experimental) and €253·1 (control), 96·6% of participants (experimental) remained free of pressure ulcers, compared with 88·1% (control). The cost per patient free of ulcer was €213·9 (experimental) and €287·3 (control). Projected annual costs were estimated for the 588 (53·5%) residents in the 12 study sites requiring repositioning. The cost would be €1·59 m (experimental) and €2·10 m (control), a cost difference of €510,000. This represents a difference of 58·8 hours of nurse time, equivalent to approximately 12 full time nurses across the 12 sites. CONCLUSION: Repositioning every 3 hours, using 30° tilt, has been shown to be more effective in less costly in terms of nurse time compared with standard care. RELEVANCE TO CLINICAL PRACTICE: Repositioning individuals at risk of pressure ulcer development makes both economic and clinical sense, thereby supporting the EPUAP/NPUAP 2009 guidelines.

Risk assessment tools for the prevention of pressure ulcers.

BACKGROUND: Pressure ulcer risk assessment is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines however it is not known whether using a risk assessment tool makes a difference to patient outcomes. A review was conducted to clarify the role of pressure ulcer risk assessment in clinical practice. OBJECTIVES: The objective of this review was to determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. SEARCH STRATEGY: The following databases were searched: MEDLINE (January 1966 to April Week 3, 2008); EMBASE (1974 to Week 17, 2008); CINAHL (1982 to April Week 4, 2008); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 2, 2008); The Wounds Group Specialised Register (searched 29/4/2008). There were no restrictions on articles on the basis of language or date of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of structured, systematic, pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools were considered for this review. DATA COLLECTION AND ANALYSIS: Titles and, where available, abstracts of the studies identified by the search strategy were assessed by two authors independently for their eligibility. Full versions of potentially relevant studies were obtained and screened against the inclusion criteria by two authors independently. MAIN RESULTS: No studies were identified that met the inclusion criteria. AUTHORS' CONCLUSIONS: Despite the widespread use of risk assessment tools for the assessment of individuals' risk of developing pressure ulcers, no randomised trials exist that compare them with unaided clinical judgement or no risk assessment in terms of rates of pressure ulceration. Therefore, we cannot conclude whether the use of structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated.

Pressure ulcer grading.

This article discusses the different aspects of classifying pressure ulcers. It aims to increase understanding of the grading methods used and how their reliability and validity may be assessed. In turn, this aims to increase the potential for nurses to enhance their assessment and pressure ulcer prevention skills.