Multi-stage versus single-stage inflation and deflation cycle for alternating low pressure air mattresses to prevent pressure ulcers in hospitalised patients: a randomised-controlled clinical trial.

INTRODUCTION: The duration and the amount of pressure and shear must be reduced in order to minimize the risk of pressure ulcer development. Alternating low pressure air mattresses with multi-stage inflation and deflation cycle of the air cells have been developed to relieve pressure by sequentially inflating and deflating the air cells. Evidence about the effectiveness of this type of mattress in clinical practice is lacking. AIM: This study aimed to compare the effectiveness of an alternating low pressure air mattress that has a standard single-stage inflation and deflation cycle of the air cells with an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. METHODS AND MATERIALS: A randomised controlled trial was performed in a convenience sample of 25 wards in five hospitals in Belgium. In total, 610 patients were included and randomly assigned to the experimental group (n=298) or the control group (n=312). In the experimental group, patients were allocated to an alternating low pressure air mattress with multi-stage inflation and deflation cycle of the air cells. In the control group, patients were allocated to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. The outcome was defined as cumulative pressure ulcer incidence (Grade II-IV). An intention-to-treat analysis was performed. RESULTS: There was no significant difference in cumulative pressure ulcer incidence (Grade II-IV) between both groups (Exp.=5.7%, Contr.=5.8%, p=0.97). When patients developed a pressure ulcer, the median time was 5.0 days in the experimental group (IQR=3.0-8.5) and 8.0 days in the control group (IQR=3.0-8.5) (Mann-Whitney U-test=113, p=0.182). The probability to remain pressure ulcer free during the observation period in this trial did not differ significantly between the experimental group and the control group (log-rank χ(2)=0.013, df=1, p=0.911). CONCLUSION: An alternating low pressure air mattress with multi-stage inflation and deflation of the air cells does not result in a significantly lower pressure ulcer incidence compared to an alternating low pressure air mattress with a standard single-stage inflation and deflation cycle of the air cells. Both alternating mattress types are equally effective to prevent pressure ulcer development.

Pressure ulcers: development and psychometric evaluation of the attitude towards pressure ulcer prevention instrument (APuP).

BACKGROUND: Pressure ulcers continue to be a significant problem in hospitals, nursing homes and community care settings. Pressure ulcer incidence is widely accepted as an indicator for the quality of care. Negative attitudes towards pressure ulcer prevention may result in suboptimal preventive care. A reliable and valid instrument to assess attitudes towards pressure ulcer prevention is lacking. AIMS AND OBJECTIVES: Development and psychometric evaluation of the Attitude towards Pressure ulcer Prevention instrument (APuP). DESIGN: Prospective psychometric instrument validation study. METHODS: A literature review was performed to design the instrument. Content validity was evaluated by nine European pressure ulcer experts and five experts in psychometric instrument validation in a double Delphi procedure. A convenience sample of 258 nurses and 291 nursing students from Belgium and The Netherlands participated in order to evaluate construct validity and stability reliability of the instrument. The data were collected between February and May 2008. RESULTS: A factor analysis indicated the construct of a 13 item instrument in a five factor solution: (1) attitude towards personal competency to prevent pressure ulcers (three items); (2) attitude towards the priority of pressure ulcer prevention (three items); (3) attitude towards the impact of pressure ulcers (three items); (4) attitude towards personal responsibility in pressure ulcer prevention (two items); and (5) attitude towards confidence in the effectiveness of prevention (two items). This five factor solution accounted for 61.4% of the variance in responses related to attitudes towards pressure ulcer prevention. All items demonstrated factor loadings over 0.60. The instrument produced similar results during stability testing [ICC=0.88 (95% CI=0.84-0.91, P<0.001)]. For the total instrument, the internal consistency (Cronbachs alpha) was 0.79. CONCLUSION: The APuP is a psychometrically sound instrument that can be used to effectively assess attitudes towards pressure ulcer prevention in patient care, education, and research. In further research, the association between attitude, knowledge and clinical performance should be explored.

Pressure ulcer prevention: development and psychometric validation of a knowledge assessment instrument.

BACKGROUND: Profound knowledge of pressure ulcers is important to enable good prevention. Validity and reliability of instruments assessing pressure ulcer knowledge are limited evaluated in previous research. AIMS AND OBJECTIVES: To develop a valid and reliable instrument to assess knowledge of pressure ulcer prevention. DESIGN: Prospective psychometric instrument validation study. METHODS: An extensive literature review was performed to develop an instrument to assess knowledge of pressure ulcer prevention. Face and content validity were evaluated in a double Delphi procedure by an expert panel of nine trustees of the European Pressure Ulcer Advisory Panel (EPUAP) who each have extensive experience in pressure ulcer care and research (PhD level). A convenience sample of 608 nurses and nursing students from Belgium and The Netherlands participated to evaluate validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, internal consistency, and stability of the instrument. The data were collected between February and May 2008. RESULTS: A 26-item instrument was developed, reflecting 6 themes expressing the most relevant aspects of pressure ulcer prevention. The content validity was excellent (CVI=0.78-1.00). Group scores of nurses with a (theoretically expected) high level of expertise were found to be statistically significantly higher than those of participants with (theoretically expected) less expertise (P<0.001). The item difficulty index of the questions ranged from 0.27 to 0.87, while values for item discrimination ranged from 0.29 to 0.65. The quality of the response alternatives was found to be good. The overall internal consistency reliability (Cronbach's alpha) was 0.77. The 1-week test-retest intraclass correlation coefficient (stability) was 0.88. CONCLUSION: The instrument demonstrated acceptable psychometric properties and can be applied in both research and practice for evaluating knowledge about pressure ulcer prevention.

[Differenciated function: prospects for the nursing profession in Belgium]. / Différenciation de fonction: quelles perspectives dans le cadre de la profession infirmière en Belgique?

The hospital and medical contexts are undergoing profound change. All professions must follow this evolution, in particular, the nurse profession. The care offer and the care demand are unbalanced: the clinical situations become more complex and the staff is insufficient quantity. The function differentiation can be a solution for the nurse profession. The aim of this study is to evaluate the feasibility of the function differentiation for the nurse profession in Belgium. Based on 364 "patient situations a derived from hospital experiences, required activities and competencies are depicted by more 200 nurses; the complexity of each competency is also evaluated by standardized scales of complexity. A cluster analysis is performed in order to pool all identified competencies. For each department, four groups are identified; each group is relevant on the statistical level but also on the clinical level. The results speak for a function differentiation in a vertical way, but not in a horizontal way between several different departments, in particular for the competencies needed a clinical judgement because these competencies are too specific by department, In conclusion, a function differentiation can be envisaged for the nurse profession in Belgium. Several models from foreign countries set an example for the practical modalities. Several advices in terms of education, lawful framework, interdisciplinary, and collaboration are formulated

Expressive language in persons with Prader-Willi syndrome.

The aim of the present study was to add to the delineation of the prevalence and nature of language difficulties in Prader-Willi syndrome (PWS). Subjects of this study were 32 Dutch speaking individuals (20 males, 12 females), with chronological ages ranging from 4;6 to 29,5 and total IQ ranging from 40 to 94. Spontaneous speech samples were subjected to a consensus orthographic transcription and analysed by means of TOAST, a Dutch standardized diagnostic instrument to investigate spontaneous language production. It was found that expressive language is usually problematic in PWS. Clearly, different linguistic levels are affected and some levels are more prone to difficulty than others. In general morphosyntax appears to be poor, whereas phonology is fairly good. Difficulties with vocabulary and/or pragmatics may be present as well. Considerable inter-individual variation was found as to the severity of the language problems.

Temporal scanner thermometry: a new method of core temperature estimation in ICU patients.

BACKGROUND AND AIMS: Temperature measurement is a routine task of patient care, with considerable clinical impact, especially in the ICU. This study was conducted to evaluate the accuracy and variability of the Temporal Artery Thermometer (TAT) in ICU-patients. Therefore, a convenience sample of 57 adult patients, with indwelling pulmonary artery catheters (PAC) in a 40-bed intensive care unit in a university teaching hospital was used. METHODS: The study design was a prospective, descriptive comparative analysis. Body temperature was thereby measured simultaneously with the TAT and the Axillary Thermometer (AT), and was compared with the temperature recording of the PAC. The use of vasoactive medication was recorded. RESULTS AND CONCLUSIONS: Mean temperature of all measurements was: PAC: 37.1 degrees C (SD: 0.87), TAT 37.0 degrees C (SD: 0.68) and axillary thermometer: 36.6 degrees C (SD: 0.94). The measurements of the TAT and the PAC were not significantly different (man differnce: 0.14 degrees C; SD: 0.51; p = 0.33); whereas the measurements of the PAC and the AT differed significantly (mean difference: 0.46 degerees C; SD: 0.39; p < 0.001). Mean diference in PAC versus TAT analyses, between patients with vasopressor therapy (0.12 degrees C; SD: 0.55), and without vasopressor therapy (0.19 degrees C; SD: 0.48) was not statistically significant (p = 0.47). CONCLUSION: We can conclude that the temporal scanner has a relatively good reliability with an acceptable accuracy and variability in patients with normothermia. The results are comparable to those of the AT, but they do not seem to be sufficient to prove any substantial benefit compared to rectal, oral or bladder thermometry.

Meeting the challenges for gerontological nursing in Europe: The European Nursing Academy for Care of Older persons (ENACO).

In order to support the urgent need for proactive and targeted investments in care for older persons a group of geriatric nurse specialists from different European countries convened in Leuven (Belgium) in November 2002 to launch the European Nursing Academy for Care of Older persons (ENACO). The mission of ENACO is to enhance outcomes of older persons and their caregivers through strengthening gerontological clinical nursing care, education, research and health policy within an interdisciplinary context. Specific objectives of ENACO are: 1) providing up-to-date education and training by "teaching the teachers". More specifically, the target groups are master's prepared nurses specialized in gerontology who can contribute and guide the development of gerontological/geriatric nursing care in their own country; 2) developing a core curriculum for basic gerontological nursing education in Europe and; 3) developing an European network of gerontological nursing expertise. More specifically, a web page providing opportunities for interactive communication as well as a mentoring program will be developed for nurses interested in the deepening and fine-tuning of their professional experience in care for older persons. The fact that care for older persons is high on the European agenda, the collaboration with the European Academy for Medicine of Ageing (EAMA), and other professional organizations in Europe and other parts of the world, are promising elements in the development of ENACO.

[Less frequent turning intervals and yet less pressure ulcers]. / Wisselhouding, minder frequent en toch minder decubitus.

The aim of the doctoral dissertation summarised here, was to study the effect of different turning intervals and to optimise this method of pressure ulcer prevention. Prior to the main study, the pressure reducing effect of mattresses, cushions, sitting and lying positions was investigated. Based on the results of 3 pre-studies, 4 different turning schemes were compared in a randomised controlled trial in 838 high-risk nursing home residents. Turning every 4 hours in combination with the use of a pressure reducing viscoelastic mattress reduced the number of pressure ulcers significantly compared to the other 3 schemes: turning every 6 hours on a viscoelastic mattress, and turning every 2 or 4 hours on a non-pressure reducing mattress.

Aerodynamic and acoustic characteristics of voice in Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is a multisystem disorder caused by DNA abnormalities involving chromosome 15. Major characteristics are infant hypotonia, hypogonadism, mental retardation, a short stature, atypical facial appearance, and the onset of obesity due to insatiable hunger in early childhood. Also, speech and language abnormalities have been reported including voice disorders. These have seldom been studied in detail, however. This paper reports the results of an acoustic and aerodynamic investigation of the voice in 22 individuals with PWS. Two age groups were distinguished, a group of children [chronological age (CA) 6 years, 7 months through 11 years, 7 months; total intelligence quotient (TIQ) 40-88] and a group of adolescents and adults (CA 17 years, 1 month through 29 years, 5 months; TIQ 41-94). Both aerodynamic and acoustic parameters were obtained and compared with normative data from the Belgian Study Group on Voice Disorders. It was found that voice difficulties do commonly occur in individuals with PWS including impairment of frequency levels, voice quality, and poor aerodynamic capabilities.

Preventing pressure ulcers: an evaluation of four operating-table mattresses.

Pressure is a major factor in the development of pressure ulcers. This research focused on assessing the pressure-reducing effects of operating-table mattresses. Five mattresses were tested: a standard operating-table mattress, a foam mattress, a gel mattress, a visco-elastic polyether mattress, and a visco-elastic polyurethane mattress. Four intraoperative postures were evaluated: supine, lateral, fossa, and the Miles-Pauchet position. Interface pressure measurements were performed on 36 healthy volunteers. The foam mattress and the gel mattress seem to have little or no pressure-reducing effect; the polyurethane mattress and the polyether mattress reduce interface pressure significantly better (p < .001); but none of the mattresses reduce pressure sufficiently to prevent the occurrence of pressure ulcers.

Do pressure relief cushions really relieve pressure?

In a laboratory setting, interface pressures of 29 cushions and a sheepskin were measured on 20 healthy volunteers. Each participant was seated in an upright posture with their back against the back of the chair, hands resting on the lap, knees bent at an angle of 90 degrees, and feet resting on the floor. Only 13 cushions had any pressure-reducing effect. Gel cushions and sheepskins appear to have no pressure-reducing effect. The category of foam includes both cushions that reduce interface pressure very well and cushions that increase interface pressure. The lowest interface pressures were measured on air cushions and on some foam cushions.

The effect of position and mattress on interface pressure.

The aim of this investigation was to determine which positions resulted in the lowest pressures to the skin of persons lying in bed. Pressures were recorded in 10 different lying positions on 2 mattresses in 62 healthy volunteers. The study revealed that the 30 degrees semi-Fowler position and the prone position resulted in the lowest interface pressures. The 30 degrees laterally inclined position had lower pressure readings than the 90 degrees side lying position; 90 degrees side lying position gives the highest pressure readings and thus should be avoided. A Tempur polyethylene-urethane mattress reduces interface pressures by 20 to 30% in comparison to a standard hospital mattress (12-cm-thick cold foam).

Sitting posture and prevention of pressure ulcers.

The aim of this study was to gain insight about the influence of body posture on the pressure at the seat surface and to establish to what extent different seat cushions designed for incontinent patients reduce maximum pressures. Pressures were measured for 56 healthy volunteers in eight postures using four cushions. The posture in which the lowest maximum pressure was measured was the sitting-back posture with the lower legs on a rest. If the seat could not be tilted back, the maximum pressure in the upright sitting posture with the feet on the ground was significantly lower than sitting upright with the legs supported on a rest. Sliding down and slouching caused the highest maximum pressure. Regular checking of the posture and using positioning cushions should form part of any pressure-ulcer prevention protocol. The four selected cushions each have different pressure-reducing effects. A thick air cushion (Repose) has the lowest maximum pressure and is significantly better than the other cushions at reducing the high pressure when slouching or sliding down.

The risk of pressure sores: a conceptual scheme.

Based on a review of the literature related to the prediction and prevention of pressure sores, a conceptual scheme on pressure sores in introduced. The article highlights the four elements of the scheme: pressure, shearing force, tissue tolerance for pressure and tissue tolerance for oxygen. Factors influencing pressure and shearing forces, the pressure distribution capacity of tissue, the oxygen need of tissue and oxygen supply to tissue are discussed.

[The effect of position and mattress on the development of pressure sores]. / Het effect van de houding en de matras op het ontstaan van drukletsels.

The aim of this investigation was to determine which positions were associated with the lowest pressures to the skin in persons lying in bed. The pressure was recorded in ten different lying positions on two mattresses in 26 healthy volunteers. The semi Fowler position and the prone position were associated with a very low pressure. The 30 degrees laterally inclined position had significantly lower pressure than the classical 90 degrees side lying position. The highest pressure was measured in the 90 degrees side lying position and thus it should be avoided. A polyethylene-urethane mattress reduced pressure by 20 to 30% in comparison to a standard hospital mattress.

[Tissue tolerance and the risk of decubitus]. / Weefseltolerantie en het risico op decubitus.

Based on a review of the literature on prediction and prevention of pressure sores, a conceptual scheme is introduced. The three determinants--pressure, shearing force and tissue tolerance--are discussed.