Predictive validity of the Braden scale for assessing risk of developing pressure ulcers and dependence-related lesions.

OBJECTIVE: In 2014, a new theoretical model explained the mechanism of the development of pressure ulcers (PUs) and that of seven types of lesions known as dependence-related lesions (DRL). The aim of this study was to calculate the incidence of DRL that have been classified as PUs and to check the predictive validity of the Braden scale for assessing DRL in accordance with the new theoretical model in an intensive care unit (ICU). Method This longitudinal, prospective study was conducted in a Spanish ICU. The patients were monitored for 14 days in the ICU until they developed DRL, died, or were discharged. The patients' risk of developing DRL was assessed each day using the Braden scale. The following parameters were taken as reference for validating the scale: sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV, respectively), relative risk (RR) and the area under the receiver operating characteristic (ROC) curve. RESULTS: Of the 295 patients included in the study, 27.5% developed DRL, which 50.6% were categorised as PUs, 17.3% caused by moisture, and 13.6% caused by friction. The rest were categorised as caused by a combination of factors. Risk according to the Braden scale was greater in the group of patients with DRL than in the group of patients without. The highest risk score provided the best predictive validity parameters for the DRL (Se 0.90, Sp 0.26, PPV 0.31, NPV 0.78 and RR 3.15 [confidence interval (CI) 95%: 1.42-6.96]). These vaules show the individuals at risk are well detected, although it is at the expense of generating a number of false positive cases. CONCLUSIONS: The Braden scale has demonstrated a moderate capacity for predicting PUs and DRL caused by moisture, but no capacity for predicting DRL caused by friction.

Adecuación del plan de cuidados ante el diagnóstico de úlcera terminal de Kennedy / The adapting of a care plan after Kennedy terminal ulcer diagnosis

Varón de 69 años procedente de urgencias que ingresa en la unidad de cuidados intensivos por insuficiencia respiratoria grave. Tras fracaso de ventilación mecánica no invasiva se procede a intubación orotraqueal. A las 48h del ingreso se detecta úlcera de categoría I en coxis. Transcurridas 8h, la existencia de doble eritema (el segundo más oscuro que el primero) con desplazamiento entre 30-45° sobre la prominencia ósea hizo pensar en una lesión de tejidos profundos. La progresión a categorías superiores se produce en las 24h siguientes. Las características de la lesión, su forma de presentación y su rápida evolución nos conducen al diagnóstico de úlcera terminal de Kennedy (KTU). Tras 72h de ingreso, durante las que se descartan causas agudas de descompensación, se decide limitación del tratamiento de soporte vital. Se elabora un plan de cuidados individualizado dirigido a identificar los problemas de un paciente con KTU que evoluciona de situación crítica a terminal. Nuestros objetivos generales (NOC) fueron la adecuación del plan de cuidados partiendo de un planteamiento realista. Las intervenciones enfermeras (NIC) contemplaban acciones tales como el manejo del dolor, tratamiento conservador de la lesión, cuidados en la agonía y apoyo en la toma de decisiones a la familia. Conclusión: El diagnostico de KTU fue de ayuda para la toma de decisiones del equipo a la hora de plantearse la limitación del tratamiento del soporte vital y, a su vez, permitió la adecuación del plan de cuidados

A 69 year old man was admitted to the Intensive Care Unit (ICU) from the Emergency Department due to severe respiratory failure. Due to unsuccessful non-invasive mechanical ventilation, endotracheal intubation was performed. A category I ulcer in coccyx was detected 48h after admission. Eight hours later, a double erythema (the second one darker than the first one) with displacement between 30-45° over the bony prominence suggested there was a deep tissue injury. The lesion progressed rapidly during the next 24h. The shape and the rapid evolution of the injury lead us to diagnose a Kennedy terminal ulcer (KTU). At 72h after the admission, and once the causes of acute decompensation were ruled out, limitation of life-sustaining treatment was decided. An individualised plan of care was drawn up with the aim of identifying problems in a patient with KTU evolving from a critical to a terminal situation. Our overall objectives (NOC) were to adapt the care plan based on a realistic approach. Nursing interventions (NIC) included actions such as pain management, conservative treatment of the injury, agony care and support to help the family to make decisions. Conclusion: The diagnosis of KTU helped the health care team in the decision-making process when they considered limiting the life support, as well as in the adapting of the care plan to the actual situation

[The adapting of a care plan after Kennedy terminal ulcer diagnosis]. / Adecuación del plan de cuidados ante el diagnóstico de úlcera terminal de Kennedy.

A 69 year old man was admitted to the Intensive Care Unit (ICU) from the Emergency Department due to severe respiratory failure. Due to unsuccessful non-invasive mechanical ventilation, endotracheal intubation was performed. A category I ulcer in coccyx was detected 48h after admission. Eight hours later, a double erythema (the second one darker than the first one) with displacement between 30-45° over the bony prominence suggested there was a deep tissue injury. The lesion progressed rapidly during the next 24h. The shape and the rapid evolution of the injury lead us to diagnose a Kennedy terminal ulcer (KTU). At 72h after the admission, and once the causes of acute decompensation were ruled out, limitation of life-sustaining treatment was decided. An individualised plan of care was drawn up with the aim of identifying problems in a patient with KTU evolving from a critical to a terminal situation. Our overall objectives (NOC) were to adapt the care plan based on a realistic approach. Nursing interventions (NIC) included actions such as pain management, conservative treatment of the injury, agony care and support to help the family to make decisions. CONCLUSION: The diagnosis of KTU helped the health care team in the decision-making process when they considered limiting the life support, as well as in the adapting of the care plan to the actual situation.

Validación de las escalas de valoración de riesgo de úlceras por presión EMINA y EVARUCI en pacientes críticos / Validation of EMINA and EVARUCI scales for assessing the risk of developing pressure ulcers in critical patients

Objetivo: Contribuir a la validación de las escalas EMINA y EVARUCI en el paciente crítico para posteriormente comparar su capacidad predictiva en este mismo contexto. Método: Estudio prospectivo desde diciembre del 2012 hasta junio del 2013. Ámbito: Unidad de Cuidados Intensivos polivalente de 14 camas de hospital de referencia de 2 áreas sanitarias. Pacientes: Incluidos mayores de edad y sin úlceras al ingreso. En estudio hasta que desarrollaron úlcera grado i o superior, fueron defunción, alta o su estancia superó los 30 días. Variables de interés principales: presencia de úlcera, puntuación diaria de riesgo de desarrollar úlceras mediante valoración EMINA y EVARUCI. La validez de ambas escalas se calculó mediante sensibilidad, especificidad, valor predictivo positivo y negativo. El nivel de significación se estableció para p ≤ 0,05. Resultados: Se estudió a 189 pacientes. El 67,2% eran hombres con una edad media ± desviación estándar de 59,4 ± 16,8) años, 53 (28%) desarrollaron úlceras, siendo la tasa de incidencia de 41 úlceras por cada 1.000 días de ingreso. El día medio de aparición fue de 7,7 ± 4,4 días y la localización más frecuente, sacro. La sensibilidad y la especificidad para la media de las observaciones fue de 94,34 (87,17-100) y 33,33 (25,01-41,66) para la escala EMINA para riesgo > 10 y 92,45 (84,40-100) y 42,96 (34,24-51,68) para EVARUCI riesgo > 11. Conclusiones: No se hallaron diferencias en la capacidad predictiva de ambas escalas. Para sensibilidades > 90%, las escalas se muestran poco específicas en la detección del riesgo de úlceras en el paciente crítico

Objective: To contribute to the validation of the EMINA and EVAUCI scales for assessing the risk of pressure ulcers in the critical patient and compare their predictive capacity in this same context. Method: Prospective study from December 2012 until June 2013. Setting: Polyvalent intensive care unit of 14 beds in a reference hospital for two sanitary areas. Patients: patients of 18 years of age or older and without pressure ulcers were included. They were followed until development of a pressure ulcer of grade I or greater, medical discharge, death or 30 days. Main variables: presence of ulcers, daily score of the risk of developing pressure ulcers through EMINA and EVARUCI evaluation. The validity of both scales was calculated using sensitivity, specificity, and positive and negative predictive value. The level of significance was P ≤ 0.05. Results: A total of 189 patients were evaluated. 67.2% were male with a mean age of 59.4 (DE: 16,8) years old, 53 (28%) developed pressure ulcers, being the incidence rate of 41 ulcers per 1000 admission days. The mean day of diagnosis was 7.7 days (DE: 4,4) and the most frequent area was the sacrum. The sensitivity and specificity for the mean of observations was 94.34 (IC95% 87.17-100) and 33.33 (IC95% 25.01-41.66) for the EMINA scale for a risk > 10 and 92.45 (IC95% 84.40-100) and 42.96 (IC95% 34.24-51.68) for the EVARUCI scale for a risk of > 11. Conclusions: No differences were found in predictive capacity of both scales. For sensitivities > 90%the scales show to be insufficiently specific in the pressure ulcer risk detection in critical patients

[Validation of EMINA and EVARUCI scales for assessing the risk of developing pressure ulcers in critical patients]. / Validación de las escalas de valoración de riesgo de úlceras por presión EMINA y EVARUCI en pacientes críticos.

OBJECTIVE: To contribute to the validation of the EMINA and EVAUCI scales for assessing the risk of pressure ulcers in the critical patient and compare their predictive capacity in this same context. METHOD: Prospective study from December 2012 until June 2013. SETTING: Polyvalent intensive care unit of 14 beds in a reference hospital for two sanitary areas. PATIENTS: patients of 18 years of age or older and without pressure ulcers were included. They were followed until development of a pressure ulcer of grade I or greater, medical discharge, death or 30 days. MAIN VARIABLES: presence of ulcers, daily score of the risk of developing pressure ulcers through EMINA and EVARUCI evaluation. The validity of both scales was calculated using sensitivity, specificity, and positive and negative predictive value. The level of significance was P≤0.05. RESULTS: A total of 189 patients were evaluated. 67.2% were male with a mean age of 59.4 (DE: 16,8) years old, 53 (28%) developed pressure ulcers, being the incidence rate of 41 ulcers per 1000 admission days. The mean day of diagnosis was 7.7 days (DE: 4,4) and the most frequent area was the sacrum. The sensitivity and specificity for the mean of observations was 94.34 (IC95% 87.17-100) and 33.33 (IC95% 25.01-41.66) for the EMINA scale for a risk>10 and 92.45 (IC95% 84.40-100) and 42.96 (IC95% 34.24-51.68) for the EVARUCI scale for a risk of>11. CONCLUSIONS: No differences were found in predictive capacity of both scales. For sensitivities>90%the scales show to be insufficiently specific in the pressure ulcer risk detection in critical patients.

Úlceras por presión en el enfermo crítico: detección de factores de riesgo / No disponible

Introducción: Los pacientes ingresados en unidades de cuidados intensivos (UCI) son más vulnerables a la aparición de úlceras por presión (UPP), y es por ello que allí se registran los mayores índices de incidencia y prevalencia. El objetivo del estudio fue detectar los factores de riesgo para la aparición de UPP en los pacientes críticos. Material y método Se trata de un estudio observacional y prospectivo. Se incluyeron todos los pacientes ingresados > 24 h desde octubre de 2009 hasta junio de 2010. Variable dependiente: aparición de UPP. Variables independientes: escala (..)

Introduction: Patients admitted to intensive care units (ICU) are more vulnerable to the appearance of pressure ulcers. This is the reason why the highest rates of pressure ulcers (PU) incidence and prevalence are found in the ICU. This study has aimed to identify risk factors related to the appearance of PU in critically ill patients. Patients and method: This was a prospective and observational study that included all patients admitted for more than 24 h from October 2009 to June 2010. Dependent (..)(AU)

[Pressure ulcers in the critical patient: detection of risk factors]. / Úlceras por presión en el enfermo crítico: detección de factores de riesgo.

INTRODUCTION: Patients admitted to intensive care units (ICU) are more vulnerable to the appearance of pressure ulcers. This is the reason why the highest rates of pressure ulcers (PU) incidence and prevalence are found in the ICU. This study has aimed to identify risk factors related to the appearance of PU in critically ill patients. PATIENTS AND METHOD: This was a prospective and observational study that included all patients admitted for more than 24 h from October 2009 to June 2010. Dependent variable: Appearance of PU. INDEPENDENT VARIABLES: APACHE II score, risk assessment score (EMINA), body mass index (BMI), support surface, nutrition, norepineprhine, sedation and care support devices. Data analyses: Kaplan-Meyer survival and Cox regression analysis. Significance p < 0.05. RESULTS: A total of 236 patients were included. A significant association was found to BMI≥30 (RR: 2.51), EMINA >10 (RR: 2.96), hyperproteic nutrition (RR: 0.946), turning (RR: 0.88), sedation (RR: 0.95), polyurethane nasogastric feeding tube (RR: 0.94), dynamic support surface (RR:0.88). Significant association of p < 0.1 for Norepinephrine (RR: 2.34). CONCLUSIONS: BMI≥ 30, EMINA and norepinephrine are predictive factors of risk for PU development. Sedation days, dynamic support surfaces, hyperproteic nutrition, turning, and polyurethane nasogastric feeding tube were established as protective factors against PU.

Prevención de la neumonía asociada a la ventilación mecánica: estudio comparativo de dos métodos de higiene oral / Prevention of mechanical ventilator-associated pneumonia: a comparison of two different oral hygiene methods

IntroducciónLa higiene oral (HO) forma parte de la seguridad del paciente en la prevención de neumonía asociada a ventilación mecánica (NAV). El índice de placa dental (IP) se considera un indicador de calidad de HO. Hipótesis: la asociación cepillo dental eléctrico+HO convencional en pacientes intubados disminuye el IP y reduce el porcentaje de NAV.ObjetivoVerificar la disminución del IP en pacientes sometidos a HO+cepillo dental eléctrico y su asociación a disminución de NAV.Material y métodoEstudio prospectivo, aleatorizado, simple ciego de 3 años de duración, en un servicio de medicina intensiva polivalente de 14 camas. Incluidos pacientes ingresados con ventilación mecánica más de 48 horas sin infección respiratoria. Pacientes aleatorizados en dos grupos: estándar (GS) (HO con clorhexidina) y raspall (GR) (estándar+cepillo eléctrico). La NAV se identificó por criterios clínicos, médicos y microbiológicos. Se midieron diariamente IP y halitosis. Recogidos frotis oral y faríngeo los primeros 5 días.ResultadosTotal de la muestra, 147 pacientes. Media de edad, 53,9±17,5. Sin diferencias significativas en cuanto a disminución de NAV entre GS y GR (OR=0,78; IC del 95%, 0,36-1,68; p=0,56). La relación halitosis/índice de placa fue p=0,7. El valor de IP al quinto día fue 1,98 (n=60) en GR y 2,04 (n=57) en GS (p=0,3). El valor de IP al décimo día fue 1,68 (n=29) en GR y 1,91 (n=32) en GS (p=0,7).ConclusionesHay una tendencia hacia la disminución del IP, que es más evidente en el GR que en el GS. No hay relación entre NAV y mayor IP o halitosis(AU)

IntroductionOral hygiene (OH) forms a part of the patient's safety in the prevention of mechanical ventilator-associated pneumonia (VAP). The dental plaque index (DP) is considered as a quality marker for OH.HypothesisThe association of electric toothbrush and conventional OH in intubated patients decreases the DP and incidence of VAP.ObjectiveTo verify the reduction of DP in patients receiving OH and electric toothbrush and its association with to the decrease of VAP incidence.Materials and methodsA 3-year long randomized, single blind and prospective study conducted in a 14-bed polyvalent intensive care unit. Patients were included when there was more than 48hours of mechanical ventilation and no expected respiratory infection. Patients were randomized into two groups: Standard (OH with chlorhexidine) (GS) and Raspall (Standard OH with electric dental brush) (GR). The VAP was identified following clinical, medical and microbiological criteria. The DP and halitosis were observed daily. Oral and pharyngeal swabs were collected during the first 5 days.Results147 patients were included. Mean age was 53.9±17.5. No significant differences were found in the VAP incidence between the two groups (OR=0.78; 95% IC, 0.36-1.68; p=0.56). The relation between halitosis and DP was p=0.7. The dental plaque index on the 5th day was 1.98 (n=60) in GR and 2.04 (n=57) in GS (p=0.3). The dental plaque index on the 10th day was 1.68 (n=29) in GR and 1.91 (n=32) in GS (p=0.7).ConclusionsThere is a tendency towards a decrease in the DP which is clearing in the GR group and no relation between VAP and greater DP or halitosis(AU)

[Prevention of mechanical ventilator-associated pneumonia: a comparison of two different oral hygiene methods]. / Prevención de la neumonía asociada a la ventilación mecánica: estudio comparativo de dos métodos de higiene oral.

INTRODUCTION: Oral hygiene (OH) forms a part of the patient's safety in the prevention of mechanical ventilator-associated pneumonia (VAP). The dental plaque index (DP) is considered as a quality marker for OH. HYPOTHESIS: The association of electric toothbrush and conventional OH in intubated patients decreases the DP and incidence of VAP. OBJECTIVE: To verify the reduction of DP in patients receiving OH and electric toothbrush and its association with to the decrease of VAP incidence. MATERIALS AND METHODS: A 3-year long randomized, single blind and prospective study conducted in a 14-bed polyvalent intensive care unit. Patients were included when there was more than 48hours of mechanical ventilation and no expected respiratory infection. Patients were randomized into two groups: Standard (OH with chlorhexidine) (GS) and Raspall (Standard OH with electric dental brush) (GR). The VAP was identified following clinical, medical and microbiological criteria. The DP and halitosis were observed daily. Oral and pharyngeal swabs were collected during the first 5 days. RESULTS: 147 patients were included. Mean age was 53.9±17.5. No significant differences were found in the VAP incidence between the two groups (OR=0.78; 95% IC, 0.36-1.68; p=0.56). The relation between halitosis and DP was p=0.7. The dental plaque index on the 5th day was 1.98 (n=60) in GR and 2.04 (n=57) in GS (p=0.3). The dental plaque index on the 10th day was 1.68 (n=29) in GR and 1.91 (n=32) in GS (p=0.7). CONCLUSIONS: There is a tendency towards a decrease in the DP which is clearing in the GR group and no relation between VAP and greater DP or halitosis.

[Education as a key piece in the prevention and good course of pressure ulcers]. / La educación como pieza clave en la prevención y buena evolución de las úlceras por presión.

OBJECTIVE: To evaluate if an education program for the nursing staff helps to reduce the incidence of pressure ulcers and prevent their poor evolution. MATERIAL AND METHODS: A prospective and observational study where the prevention and educational methods have been used to prevent and treat pressure ulcers. All patients admitted to Intensive Care Unit during one year were included (six months of basal period and six months of post-training period). The following variables were analyzed: incidence of Pressure Ulcers, risk score according to EMINA, ulcer grade and location. RESULTS: A total of 134 ulcers were identified in the 69 patients (14.37%) with pressure ulcers included in the basal period. Forty-four patients (7.88%) of the patients in the post-training period developed 77 pressure ulcers. The significance level was p < 0.01, OR: 0.40 (95% CI: 0.26-0.62). Fifteen of the 211 pressure ulcers evolved to grade III-IV p > 0.20. CONCLUSIONS: Conducting a training program in the application of standardized prevention methods for the nursing staff reduces the incidence of pressure ulcers.

La educación como pieza clave en la prevención y buena evolución de las úlceras por presión / Education as a key piece in the prevention and good course of pressure ulcers

Objetivo. Evaluar si la educación dirigida a los profesionales de enfermería disminuye laincidencia de úlceras por presión (UPP) y su mala evolución.Material y métodos. Estudio prospectivo, observacional, basado en medidas educacionalessobre prevención y tratamiento. Incluyó a todos los pacientes ingresados en elServicio de Medicina Intensiva durante un año (seis meses periodo basal [PB] y seis mesesperiodo pos-educacional [PE]). Las variables fueron incidencia de UPP, riesgo según escalaEMINA, grados y localización.Resultados. Pacientes ulcerados en PB 69 (14,37%) con 134 UPP. En PE 44 pacientes(7,88%) con 77 UPP. Nivel de signifi cación p < 0,01, odds ratio: 0,40 (intervalo de confi anzadel 95%; 0,26-0,62).Del total de 211 UPP, 15 (7,10%) evolucionaron a grado III-IV (11 en PB y 4 en PE); p > 0,20.Conclusiones. La formación de los profesionales en cuanto a la aplicación de medidaspreventivas estandarizadas disminuye la incidencia de UPP(AU)

Objective. To evaluate if an education program for the nursing staff helps to reduce theincidence of pressure ulcers and prevent their poor evolution.Material and methods. A prospective and observational study where the prevention andeducational methods have been used to prevent and treat pressure ulcers. All patients hasadmittedto Intensive Care Unit during one year were included (six months of basalperiod and six months of post-training period). The following variables were analyzed:incidence of Pressure Ulcers, risk score according to EMINA, ulcer grade and location.Results. A total of 134 ulcers were identifi ed in the 69 patients (14.37%) with pressureulcers included in the basal period. Forty-four patients (7.88%) of the patients in thepost-training period developed 77 pressure ulcers. The signifi cance level was p < 0.01,OR: 0.40 (95% CI: 0.26-0.62). Fifteen of the 211 pressure ulcers evolved to grade III-IV p> 0.20.Conclusions. Conducting a training program in the application of standardized preventionmethods for the nursing staff reduces the incidence of pressure ulcers(AU)