Racial Disparities and Pressure Injuries Among Hospitalized Patients.

OBJECTIVE: To describe the demographic factors, hospitalization-related factors, comorbid states, and social determinants of health among racial groups in a sample of patients with a primary or secondary diagnosis of pressure injury (PI) admitted to New Jersey hospitals during the year 2018. METHODS: Researchers conducted a retrospective analysis of the Health Care Utilization Project's 2018 New Jersey State Inpatient Database. Patients with a primary or secondary diagnosis of PI (sacrum, buttocks, or heels; N = 17,781) were included in the analytic sample. Analysis compared patients who identified as Black (n = 3,515) with all other racial groups combined (n = 14,266). RESULTS: A higher proportion of Black patients were admitted for a PI (P < .001) and had higher proportions of stage 4 PIs (P < .001) but a lower proportion of stage 1 PIs (P < .001). Higher proportions of Black patients were younger, resided in lower income communities, and identified Medicaid as their primary payor source. CONCLUSIONS: Results highlight the racial disparities that exist among patients with PIs in this diverse state and may represent a much larger problem. Clinical research examining the impact of skin tone rather than by racial group is needed. The impact of racial disparities on social determinants of health with regard to PIs remains largely unknown, but its importance cannot be underestimated.

Examining Social Risk Factors in a Pressure Ulcer Quality Measure for Three Post-Acute Care Settings.

OBJECTIVE: To describe and explore relationships between social demographic factors and incidence or worsening of pressure ulcer scores among post-acute care (PAC) settings. DESIGN: The authors present the incidence of new or worsening pressure ulcers stratified by self-reported patient race and sex. Investigators used logistic regression modeling to examine relative risk of developing new or worsened pressure ulcers by sociodemographic status and multiple regression modeling to estimate the relative contribution of facility-level factors on rates of new or worsening pressure ulcers. SETTING: Three PAC settings: long-term care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities. PARTICIPANTS: Medicare Part A residents and patients with complete stays in PAC facilities during 2015. MAIN OUTCOME MEASURE: The incidence of new or worsened pressure ulcers as calculated using the specifications of the National Quality Forum-endorsed pressure ulcer quality measure #0678. MAIN RESULTS: The sample included 1,566,847 resident stays in 14,822 skilled nursing facilities, 478,292 patient stays in 1,132 inpatient rehabilitation facilities, and 121,834 patient stays in 397 long-term care hospitals. Significant differences in new or worsened pressure ulcer incidence rates by sociodemographic factors were found in all three settings. Black race, male sex, and advanced age were significant predictors of new or worsened ulcers, although controlling for health conditions reduced the racial disparity. The authors noted significant differences among facilities based on ownership type, urban/rural location, and sociodemographic makeup of facilities' residents/patients. CONCLUSIONS: There is evidence of disparities in the incidence of new or worsened pressure ulcers across PAC settings, suggesting publicly available quality data may be used to identify and ameliorate these problems.

Pressure injuries in people with darker skin tones: A literature review.

AIMS AND OBJECTIVES: In this article, we aimed to explore the literature to ascertain what research evidence exists in relation to the identification of pressure injuries in people with dark skin tones. BACKGROUND: Pressure injuries development has been widely researched and documented; however, much of this work does not address ethnicity or race and assumes Caucasian-ness. Thus, the perceptions of people with dark skin tones and the influence of skin pigmentation on identification and management of pressure injuries is under examined. DESIGN: Literature review. METHODS: A comprehensive electronic database search was undertaken of PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane and British Nursing Index (BNI) between 1990-July 2016. Alongside the electronic data, journals, books, papers from conferences, relevant national and international organisations and reference lists were also used to help source key studies. RESULTS: A search of the literature revealed 11 relevant articles. The foci of studies included the following: risk of sustaining a pressure injuries based on skin tones, identification of pressure injuries amongst people with dark skin tones, pressure injuries and place of care and socio-economic impact on pressure injuries development. Overall, findings indicate that people with darker skin tones are more likely to develop higher stage pressure injuries. Reasons for this are not fully elucidated; however, it may be associated with current skin assessment protocols being less effective for people who have darker skin tones resulting in early damage arising from pressure not being recognised. CONCLUSION: From the literature reviewed, it can be seen that there is a lack of guidance and evidence, and people with darker skin tones are more likely in comparison with people presenting as Caucasian to develop higher stage pressure injuries. RELEVANCE TO CLINICAL PRACTICE: The current literature suggests a need for researchers and clinicians to consider skin tone variances rather than ethnicity when exploring comprehensive skin assessment.

Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission.

BACKGROUND: Pressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers. PURPOSE: To assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets. METHODS: Minimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2-4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions. RESULTS: A significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity. CONCLUSIONS: Reducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.

Fatores relacionados à ocorrência de eventos adversos em pacientes idosos críticos / Factores relacionados con el acaecimiento de eventos adversos en pacientes críticos de edad avanzada / Factors associated with the occurrence of adverse events in critical elderly patients

RESUMO Objetivo: identificar os fatores relacionados à ocorrência de eventos adversos em pacientes idosos críticos internados em Unidade de Terapia Intensiva segundo características demográficas e clínicas. Método: estudo de coorte retrospectivo realizado em nove unidades de um hospital universitário. Os dados foram coletados dos prontuários e do acompanhamento de passagens de plantão de enfermagem. Utilizou-se o Teste-t/Mann-Whitney, Qui-quadrado e Regressão Logística para verificar associações. Nível de significância de 5%. Resultados: do total de 315 idosos, 94 sofreram eventos. Os que sofreram eventos eram homens (60,6%), com média de idade de 70,7 anos, permanência de 10,6 dias e sobreviventes (61,7%). Dos 183 eventos, houve predomínio do tipo processo clínico e procedimento (37,1%). Houve associação entre evento adverso e tempo de permanência na unidade (p=0,000; OR=1,10; IC95%=[1,06;1,14]). Conclusão: a identificação dos eventos e fatores associados no idoso subsidiam a prevenção dessas ocorrências perante as vulnerabilidades dessa faixa etária.

RESUMEN Objetivo: identificar los factores relacionados con el acaecimiento de eventos adversos en pacientes críticos de edad avanzada según características demográficas y clínicas, internados en Unidades de Terapia Intensiva. Método: estudio de corte retrospectivo realizado en nueve unidades de un hospital universitario. Se recolectaron datos de los prontuarios y del acompañamiento de la guardia de enfermería. Las asociaciones se comprobaron mediante la Prueba de Mann-Whitney, la distribución de Pearson (ji cuadrado) y la Regresión Logística. El nivel de significación fue del 5%. Resultados: sufrieron eventos 94 personas mayores del total de 315, siendo del sexo masculino el 60,6%, con edad promedio de 70,7 años, permanencia de 10,6 días y sobrevivencia del 61,7%. De los 183 eventos, predominó el proceso clínico y el procedimiento (37,1%). Se observó que el evento adverso y el tiempo de permanencia en la unidad estaban relacionados (p=0,000; OR=1,10; IC95%=[1,06;1,14]). Conclusión: la identificación de los eventos y de los factores asociados a la vejez auxilia en la prevención de dichos sucesos frente a la vulnerabilidad de ese grupo de edad.

ABSTRACT Objective: to identify the factors associated with the occurrence of adverse events in critical elderly patients admitted to intensive care unit according to demographic and clinical characteristics. Method: a retrospective cohort study was conducted in nine units of a teaching hospital. Data were collected from medical records and from monitoring of nursing shift change. We used the t-test/Mann-Whitney, chi-square and logistic regression to test associations. Significance level of 5% was used. Results: out of the 315 elderly, 94 experienced events. Those who experienced events were men (60.6%) with mean age of 70.7 years, length of hospital stay of 10.6 days and survivors (61.7%). Most of the 183 events were clinical processes and procedures (37.1%). There was an association between adverse event and length of hospital stay in the unit (p=0.000; OR=1.10, 95% CI [1.06, 1.14]). Conclusion: the identification of associated events and factors in the elderly subsidize the prevention of these occurrences before the vulnerability of this age group.

Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study.

Pressure ulcers are common, increase patient morbidity and mortality, and costly for patients, their families, and the health care system. A retrospective study was conducted to evaluate the impact of pressure ulcers on short-term outcomes in United States inpatient populations and to identify patient characteristics associated with having 1 or more pressure ulcers. The US Nationwide Inpatient Sample (NIS) database was analyzed using the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9 CM) diagnosis codes as the screening tool for all inpatient pressure ulcers recorded from 2008 to 2012. Patient demographics and comorbid conditions, as identified by ICD-9 code, were extracted, along with primary outcomes of length of stay (LOS), total hospital charge (TC), inhospital mortality, and discharge disposition. Continuous variables with normal distribution were expressed in terms of mean and standard deviation. Group comparisons were performed using t-test or ANOVA test. Continuous nonnormal distributed variables such as LOS and TC were expressed in terms of median, and nonparametric tests were used to compare the differences between groups. Categorical data were presented in terms of percentages of the number of cases within each group. Chi-squared tests were used to compare categorical data in different groups. For multivariate analysis, linear regressions (for continuous variable) and logistic regression (for categorical variables) were used to analyze the possible risk factors for the investigated outcomes of LOS, TC, inhospital mortality, and patient disposition. Coefficients were calculated with multivariate regression with all included patients versus patients with pressure ulcers alone. The 5-year average number of admitted patients with at least 1 pressure ulcer was determined to be 670 767 (average overall rate: 1.8%). Statistically significant differences between patients with and without pressure ulcers were observed for median LOS (7 days [mean 11.1 ± 15] compared to 3 days [mean 4.6 ± 6.8]) and median TC ($36 500 [mean $72 000 ± $122 900] compared to $17 200 [mean $32 200 ± $57 500]). The mortality rate in patients with a pressure ulcer was significantly higher than in patients without a pressure ulcer (9.1% versus 1.8%, OR = 5.08, CI: 5.03-5.1, P <0.001). Pressure ulcers were significantly more common in patients who were older or had malnutrition. The results of this study confirm the importance of prevention initiatives to help reduce the negative impact of pressure ulcers on patient outcomes and costs of care.

Prayer Marks in Immigrants from Bangladesh with Diabetes Who Live in Greece.

Prayer marks (PMs) are commonly occurring dermatologic changes in muslims who pray and develop over a long period of time as a consequence of repeated and extended pressure. PMs need careful examination especially for patients with diabetes, who are more vulnerable due to predisposing factors such as venous insufficiency and peripheral neuropathy. A total of 166 patients with diabetes (150 males, 16 females) and 65 normal subjects from Bangladesh were examined for the appearance of PMs. Twenty-eight patients (16.9 %) and one normal subject (1.5 %) had PMs. The marks were not itchy or painful and they were observed on the dorsal aspect of the left foot, which was attributed to a more typical prayer position that placed pressure on the left foot. PMs are not a rare clinical entity among muslim patients with diabetes and most clinicians should be aware of it as it can be the predominant cause of an ulcer.

Statistical Approaches to Assessing Health and Healthcare Disparities.

Determining whether racial and ethnic disparities exist for a health-related outcome requires first specifying how outcomes will be measured and disparities calculated. We explain and contrast two common approaches for quantifying racial/ethnic disparities in health, with an applied example from nursing research. Data from a national for-profit chain of nursing homes in the US were analyzed to estimate racial/ethnic disparities in incidence of pressure ulcer within 90 days of nursing home admission. Two approaches were used and then compared: logistic regression and Peters-Belson. Advantages and disadvantages of each approach are given. Logistic regression can be used to quantify disparities as the odds of the outcome for one group relative to another. Peters-Belson can be used to quantify an overall disparity between groups as a risk difference and also provides the proportion of that disparity that is explained by available risk factors. Extensions to continuous outcomes, to survival outcomes, and to clustered data are outlined. Both logistic regression and Peters-Belson are easily implementable and interpretable and provide information on the predictors associated with the outcome. These disparity estimation methods have different interpretations, assumptions, strengths, and weaknesses, of which the researcher should be aware when planning an analytic approach.

Pressure ulcer and patient characteristics--A point prevalence study in a tertiary hospital of India based on the European Pressure Ulcer Advisory Panel minimum data set.

BACKGROUND: Pressure ulcers is a frequent problem in hospitalized patients. Several prevalence studies have been conducted across the globe. Little information is available regarding prevalence of pressure ulcers in India. PURPOSE: The aim was to identify the prevalence of pressure ulcers in one of the tertiary hospital in northern India and the factors associated with its development. DESIGN: A cross sectional point prevalence study. INSTRUMENTS: European Pressure Ulcer Advisory Panel (EPUAP) data collection form. METHODS: Ethics approval was obtained prior to start of the study. Total of 358 patients were enrolled in the study. All patients above 18 years of age admitted in intensive care units and wards were included in the study. Patients admitted in emergency, day care, coronary care unit were excluded because of their short duration of hospital stay (varies from 24 to 72 h usually). All patients admitted before midnight on the predetermined day were included. The Braden scale was used to identify the risk of developing pressure ulcers. European Pressure ulcer advisory panel (EPUAP) minimum data set was used to collect prevalence data. RESULTS: The overall prevalence rate was 7.8%.The sacrum and heel were more commonly affected. Grade III pressure ulcers were the most common (42.8%). CONCLUSION: The pressure ulcer prevalence rate in our hospital was lower than that published in international studies. Severe forms of pressure ulcers were commonly encountered This data provides background information that may help us in developing protocols for applying effective practices for prevention of pressure ulcers.

Are there racial-ethnic disparities in time to pressure ulcer development and pressure ulcer treatment in older adults after nursing home admission?

OBJECTIVE: The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in individuals aged 65 and older after nursing home admission. METHOD: Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters-Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes. RESULTS: More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group. DISCUSSION: Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.

Prevalence of pressure ulcers by race and ethnicity for older adults admitted to nursing homes.

Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals. [Journal of Gerontological Nursing, 40(3), 20-26.].

Conducting intervention research among underserved populations: lessons learned and recommendations for researchers.

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

Association of race and sites of care with pressure ulcers in high-risk nursing home residents.

CONTEXT: A variety of nursing home quality improvement programs have been implemented during the last decade but their implications for racial disparities on quality are unknown. OBJECTIVES: To determine the longitudinal trend of racial disparities in pressure ulcer prevalence among high-risk, long-term nursing home residents and to assess whether persistent disparities are related to where residents received care. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of pressure ulcer rates in 2.1 million white and 346,808 black residents of 12,473 certified nursing homes in the United States that used the nursing home resident assessment; Online Survey, Certification, and Reporting files; and Area Resource Files for 2003 through 2008. Nursing homes were categorized according to their proportions of black residents. MAIN OUTCOME MEASURES: Risk-adjusted racial disparities between and within sites of care and risk-adjusted odds of pressure ulcers in stages 2 through 4 for black and white residents receiving care in different nursing home facilities. RESULTS: Pressure ulcer rates decreased overall from 2003 through 2008 but black residents of nursing homes showed persistently higher pressure ulcer rates than white residents. In 2003, the pressure ulcer rate was 16.8% (95% confidence interval [CI], 16.6%-17.0%) for black nursing home residents compared with 11.4% (95% CI, 11.3%-11.5%) for white residents; in 2008, the rate was 14.6% (95% CI, 14.4%-14.8%) compared with 9.6% (95% CI, 9.5%-9.7%), respectively (P >.05 for trend of disparities). In nursing homes with the highest percentages of black residents (≥35%), both black residents (unadjusted rate of 15.5% [95% CI, 15.2%-15.8%] in 2008; adjusted odds ratio [AOR], 1.59 [95% CI, 1.52-1.67]) and white residents (unadjusted rate of 12.1% [95% CI, 11.8%-12.4%]; AOR, 1.33 [95% CI, 1.26-1.40]) had higher rates of pressure ulcers than nursing homes serving primarily white residents (concentration of black residents <5%), in which white residents had an unadjusted rate of 8.8% (95% CI, 8.7%-8.9%). CONCLUSIONS: From 2003 through 2008, the prevalence of pressure ulcers among high-risk nursing home residents was higher among black residents than among white residents. This disparity was in part related to the site of nursing home care.

Pressure ulcer prevalence among black and white nursing home residents in New York state: evidence of racial disparity?

OBJECTIVE: The occurrence of pressure ulcers (PUs) in nursing homes is a marker for poor quality of care. We examine whether differences in PU prevalence between black and white residents are due to within- or across-facility disparities. METHODS: Minimum Data Sets (2006-2007) are linked with the Online Survey Certification and Reporting database. Long-term care residents with high risk for PUs are identified. The dependent variable is dichotomous, indicating PU presence/absence. Individual race and facility race-mix are the main variables of interests.The sample includes 59,740 long-term care high-risk residents (17.4% black and 82.6% white) in 619 nursing homes. We fit 3 risk-adjusted logit models: base, conditional fixed-effects, and random-effects. RESULTS: Unadjusted PU prevalence is 14.5% (18.2% for blacks and 13.8% for whites). Overall, blacks are more likely to have PUs than whites, controlling for individual risk factors. We find no such effect within facilities after additional accounting for facility fixed effects. The effect of race is significantly different between the base and the conditional fixed-effects logit model. The random-effects and conditional fixed-effects logit models show similar results, demonstrating that higher PU presence among blacks is associated with greater facility-specific concentration of black residents. CONCLUSION: Greater PU occurrence among blacks may not result from differential within-facility treatment of blacks versus whites. Rather, blacks are more likely to reside in facilities with poorer care quality. To improve PU care for blacks, efforts should focus on improving the overall quality of care for facilities with high proportion of black residents.

Pressure ulcer prevalence and barriers to treatment after spinal cord injury: comparisons of four groups based on race-ethnicity.

OBJECTIVE: To compare the prevalence of pressure ulcer (PU) and barriers to treatment in the event of PU development as a function of race-ethnicity in persons with spinal cord injury (SCI). METHODS: Interview data were collected from three rehabilitation hospitals each of which was designated as a model SCI system of care by the United States Department of Education. There were 475 participants with similar portions of each racial-ethnic group (African-American n = 121, American-Indian n = 105, Caucasians n = 127, Hispanics n = 122). RESULTS: The lowest prevalence rates for pressure ulcers were reported by Hispanics followed by Caucasians. Logistic regression revealed racial-ethnic differences in the odds of developing a PU within the past 12 months. Social support and injury severity were also associated with risk of PU while age, gender, years since injury, and education were not. Significant racial-ethnic differences were also observed in 5 of 9 barriers to the treatment of PUs. CONCLUSION: Results suggest that variability in social support and barriers to treatment may contribute to the racial-ethnic differences in prevalence rates for PU that were observed. Future research in this area could lead to the development of strategies to enhance prevention and treatment targeted at the elimination of any racial-ethnic disparities.

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit.

AIMS AND OBJECTIVES: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). BACKGROUND: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. DESIGN: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. METHODS: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient's skin condition and stage of pressure ulcer. RESULTS: Out of the 253 patients, 72 (28.4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41.7%), stage II (45.8%), stage III (10.4%) and stage IV (2.1%). In ICU B, the incidence was 31.6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut-off score of 4. The area under the receiver-operating characteristic curve was 0.888 (confidence interval: 0.84-0.93). CONCLUSION: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.

Use of photographs for the identification of pressure ulcers in elderly hospitalized patients: validity and reliability.

To evaluate the ability of research nurses to identify pressure ulcers, the authors assembled digital photographs of the skin of 160 consenting elderly patients (80% African American, 63% women). The series included 39 photos of pressure ulcers, 109 of normal skin, and 12 of other skin conditions, determined by consensus by two experts (D.J.M. and S.H.K.). Photos were packaged electronically into eight blocks of 20, with pressure ulcer prevalence ranging from 20% to 30% per block. The eight blocks were duplicated to create two sets of 160 photos each. Each of six raters (experienced clinical research nurses), working independently, evaluated the 320 photos as if each photo depicted a different patient. For analysis, the ratings were collapsed into binary determinations (any pressure ulcer vs. none). The overall sensitivity and specificity of the ratings were 0.97 (95% confidence interval: 0.94, 0.98) and 0.81 (95% confidence interval: 0.77, 0.86), respectively. Rater-specific prevalence (range: 31.8-47.5%) exceeded the true prevalence (24.4%). Inter- and intrarater reliability coefficients were 0.69 and 0.84, respectively. Trained research nurses can accurately classify pressure ulcers from photographs, even when patients are largely non-White and the photographs depict pressure ulcers spanning all pressure ulcer stages.

Pressure ulcer prevention in black and white nursing home residents: A QI initiative of enhanced ability, incentives, and management feedback.

OBJECTIVE: To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents. DESIGN: Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods. PARTICIPANTS: All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania. MAIN OUTCOME MEASURE: The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV). RESULTS: At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends. CONCLUSION: Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.

Pressure ulcers: more lethal than we thought?

OBJECTIVE: To investigate the burden of pressure ulcer-associated mortality in the United States and to examine racial/ethnic differences and associated comorbidities. DESIGN: A descriptive study with matched odds ratio comparisons. SETTING: The United States, 1990-2001. PARTICIPANTS: Pressure ulcer-associated deaths were identified from national multiple cause-coded death records from 1990 to 2001. MAIN OUTCOME MEASURES: Age-adjusted mortality rates and matched odds ratio comparisons of pressure ulcer-associated deaths with deaths from other conditions. MAIN RESULTS: Between 1990 and 2001, pressure ulcers were reported as a cause of death among 114,380 persons (age-adjusted mortality rate, 3.79 per 100,000 population; 95% confidence interval [CI], 3.77-3.81). For 21,365 (18.7%) of these deaths, pressure ulcers were reported as the underlying cause. Nearly 80% of pressure ulcer-associated deaths occurred in persons at least 75 years old. Septicemia was reported in 39.7% of pressure ulcer-associated deaths (matched odds ratio, 11.3; 95% CI, 11.0-11.7). Multiple sclerosis, paralysis, Alzheimer disease, osteoporosis, and Parkinson disease were reported more often in pressure ulcer-associated deaths than in matched controls. Pressure ulcer-associated mortality was higher among blacks than among whites (age-adjusted rate ratio, 4.22; 95% CI, 4.16-4.27). CONCLUSION: Pressure ulcers are associated with fatal septic infections and are reported as a cause of thousands of deaths each year in the United States. Incapacitating chronic and neurodegenerative conditions are common comorbidities, and mortality rates in blacks are higher than in other racial/ethnic groups.