Pressure Ulcer Prevalence and Incidence in a Rehabilitation Hospital Susan Montgomery Hunter, MSN RN; Tressa Cathcart-Silberberg,MS RN C; Diane K. Langemo, PhD RN; Bette Olson, MS RN; Darlene Hanson, MS RN; Chris Burd, MS RN; Timothy R. Sauvage, MS RN CRNA Pressure ulcers remain a serious health problem, especially in terms of personal sufferingand economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time)and the incidence (number ofpersons developing pressure ulcers overa given time)ofpressure ulcers. Skin assessments and riskassessments of the subjects were completed using the Braden Scalefor Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.
I
t has been estimated that more than 1 million people in acute
care hospitals and nursing homes suffer from pressure ulcers (PU) (National Pressure Ulcer Advisory Panel [NPUAP], 1989). In spinal cord injured patients, the prevalence of pressure ulcers (how many patients in a given population have a pressure ulcer at any given time) ranges from 20% to 66% (Richardson & Meyer, 1981; Shannon & Skorga, 1989; Young, Bums, Bowen, & McCutchen, 1982). The incidence of pressure ulcers (how many patients develop a pressure ulcer over a specified period of time) ranges from 25% to 85% (Kerr,Stinson, &Shannon, 1981; Mawson et al., 1988; Richardson & Meyer, 1981; Staas & LaMantia, 1982; Young et al., 1982)and is highly dependent on the level of the injury and coexisting medical conditions.According to Reuler and Cooney (1981), 7% to 8% of spinal cord injured patients die from complications of pressure ulcers. In economic terms, Krouskop (1983) estimated that the cost of treating pressure ulcers in the United States, taking into account the loss of patient productivity,exceeds $2 billion annually.It has been estimated that $66 million is spent in annual hospitalization costs for newly injured spinal cord patients under treatment for pressure ulcers (Mawson et al., 1988). With such staggering amounts of money being spent on pressure ulcers-not to mention the suffering experiencedby the patients-a pressure ulcer prevention program to decrease the incidence, cost, and suffering experienced by the patients would be beneficial. In addition to decreasing financial burdens and personal suffering, a prevention program also could be used for quality assurance. With these ideas in mind, the authors undertook the study described here. Address correspondence to Susan Montgomery Hunter, MSN RN, Assistant Professor, University of North Dakota College of Nursing, PO Box 8195, University Station, Grand Forks, ND, 58202-8195.
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Intended audience This independent study offering is appropriate for all rehabilitation nurses. Objectives By reading this article, the learner will achieve the following objectives: 1. Describe typical rates of pressure ulcer prevalence in rehabilitation patients and relate them to the rates revealed by this study. 2. Discuss the reasons for the discrepancy between the prevalence and incidence of pressure ulcers in this study. The study Purpose: The extent of a problem must be established before a prevention program can be implemented and later evaluated for success (Gaymar Industries, Inc., 1987). Therefore, the authors decided to conduct a study of pressure ulcer prevalence and incidence at a rehabilitation hospital in the Midwest to establish a baseline of the status of these problems for current and future comparative purposes. This research study consisted of two phases. Phase 1 focused on the prevalence of pressure ulcers (number of patients with a pressure ulcer at a given time) among patients in a rehabilitation setting. Phase 2 focused on the incidenceof pressure ulcers (number of persons developing pressure ulcers over a set time period) in a rehabilitative setting. A third phase (not documented here) focused on the prevalence of pressure ulcers in a rehabilitation setting after a formal prevention program was instituted. Theoretical framework: The theoretical framework used for this study was that of Levine’s (1969) “conservation of structural integrity” (p. 11). The theory of conservation of structural integrity is based on the process of therapeutic nursing interventions
Vol. 17, No. Smehabilitation NursindSep-Oct 1992/239
Pressure Ulcer Prevalence and Incidence
for restoration or maintenance of the body’s structure. When there is an unfavorable adaptation, pressure ulcers can develop quite rapidly. Supportive intervention, a concept from Levine’s theory, was applied in this study through the preservation or restoration of structural integrity, thereby conserving the resources of the individual. Definitions: In this study, pressure ulcers were defined as lesions on any skin surface that occur as a result of pressure; they include reactive hyperemia as well as blisters, broken skin, or necrotic tissue. Prevalence was defined as “the number or percentage of persons with a pressure ulcer at a given time in a particular population” (Allman, 1989, p. 3 1). Incidence was defined as “the number or percentage of persons at risk who have newly developed pressure ulcers after a certain period of followup” (Allman, 1989,p. 3 1).Thefollow-upperiod was a minimum of 1% weeks to 4 weeks or until discharge. Setting: The study took place in a 79-bed nonacute rehabilitation center in the Midwest. Patients were admitted to the hospital from home or transferred from community nursing homes or hospitals. Sample: All patients 18 years of age and older who consented were included in the prevalence and incidence studies. Ambulatory back patients and short-stay patients (those in the hospital for less than 1week) were not included in the incidence study. Forty patients participated in the prevalence study. Forty different patients participated in the incidence study. Instruments:Three instrumentswere used for datacollection. These consisted of a demographic data form, a skin assessment tool, and the Braden Scale for Predicting Pressure Sore Risk (Braden & Bergstrom, 1989). The demographic tool documented data such as age, sex, diagnosis, height and weight, vital signs, activity, steroidtherapy, and smoking history. These variables were used for correlation with the prevalence and incidence of pressure ulcers. The skin assessment tool contained the definition of pressure ulcers used in the study and a full body diagram detailing all sites to be assessed. Each site was assessed and rated. The rating scales used Shea’s (1975) four stages of pressure ulcers and the standards of care for pressure ulcers developed by the International Association for Enterostomal Therapy (Standards Committee of the International Association for Enterostomal Therapy [IAET], 1988). A zero meant no redness or breakdown, while a stage I meant nonblanchable erythema, and a stage IV was a skin break extending into the subcutaneous and muscle layers. All subjects were assessed and rated systematically. Body moisture also was assessed, including urinary and fecal incontinence. The Braden Scale for Predicting Pressure Sore Risk is a summative rating scale consisting of six subscales that reflect the “critical determinantsof pressure (mobility, activity, and sensory perception) and factors influencing the tolerance of the skin and supporting structures for pressure (skin moisture, nutritional status, and friction and shear)” (Bergstrom, Demuth, & Braden, 1987, p. 417). The maximum total score is 23. Each level of the scale is mutually exclusive. The lower the scale score, the higher the risk. Interrater reliability has been reported as 88% for RNs
(r = .99) and 11% to 19% for LPNs and nurse aides (r = 27) (Bergstrom, Braden, Laguzza, & Holman, 1987). The Braden scale was used to assess data on six subscales, to acquaint staff in agencies with the tool, and toestablish mean scores for the agency patients. The interrater reliability for RNs in this setting was .98 (percent of agreement) after education sessions on the use of the Braden scale. This was obtained by having two nurses who cared for a patient independentlycomplete the Braden scale and, if the scores varied by more than one point, having a third person complete the Braden scale to establish consensus.
Table 1. Number (Prevalence) of Pressure Ulcers in a Rehabilitation Setting
(A/=40; 22 males, 18 females) Stage
I II Ill
IV
#of Males 2 1 1 0
#of #of #of PUS Females PUS 2 2 3 1 2 3 1 2 2 0
10 25 12
4 18 4
6 33 8
5
3
2
5
3
2
Total Patients 4 3 3 0
Number positive Percent positive Number of ulcers Number admitted with ulcers Number who developed ulcers after admission
Phase 1: The prevalence study Procedure: The researchers and the RN research assistants completed systematic skin assessments of all patients who verbally consented. For each patient found to have a pressure ulcer in any stage (I to IV),a demographicdata form was completed by the researchers and a Braden scale rating was done independently by twonurses whoknew the patient but who hadnot done the skin assessment (to prevent rater bias). All patients were assessed on a single day. Data analysis: Descriptive statistics were obtained using the Statistical Package for Social Sciences (SPSS). Results: From a sample of 40 patients, 10 (25%) were found to have pressure ulcers (see Table 1).Two patients had two ulcers each for a total of 12 ulcers. Five pressure ulcers were in stage I, four were in stage LI, and three were in stage III. The sizes of the ulcers varied from 0.5 cm x 0.5 cm to 16 cm x 8 cm. The 16 cm x 8 cm ulcer was a stage I. The majority were 4 cm x 4 cm in size. For patients who had pressure ulcers, the Braden scale scores ranged from 11 to 19 points with a mean of 14.
240/Sep-Oct 1992/Rehabilitation NursingNol. 17, No. 5
Discussion: This study used Shea’s (1975) classification of pressure ulcer stages and the IAET’s standards of care for pressure ulcers (Standards Committee of the IAET, 1988) and was consistent with the National Pressure Ulcer Advisory Panel (NPUAP)’sconsensus statementonpressureulcers (1989). Stage I includes nonblanchable erythema of intact skin. Stage I1 is a partial thickness skin loss. Stage 111consists of full-thickness skin loss extending down to the fascia. Subcutaneous fat is exposed. Stage IV exposes muscle and bone. Some studies have been very inconsistent in including reddened areas without skin breaks as
Table 2. Pressure Ulcer Location Stage
Total Number of Ulcers
Site
I I I
2 2 1
Both heels Sacral Right lateral malleolus
II II
2 2
Left elbow Sacral
Ill Ill Ill
1 1 1
Left lateral rnalleolus Sacral Left elbow
positive stage I ulcers. With the international acceptance of the NPUAP consensus conference definitions of stages I to IV, it is anticipated that this research problem should be eliminated. As has been stated previously, prevalence rates in rehabilitation patients can range from 20% to 66%. The prevalence rate for this study was low in comparison to rates found in previous research. If the five pressure ulcers in stage I were eliminated, which has been done in many previous studies, the prevalence rate would be 15%, which is well below the usual prevalence rates. Five of the 10patients who had pressure ulcers developed them after being admitted to the facility (see Table 1). Three of these patients had stageIulcers, onehadastageIIulcer(whichoccurred on the 15th day after admission), and one had a stage 111 ulcer (which occurred approximately 4% months prior to the audit). Those who were admitted with a pressure ulcer included two patients with stage1ulcers (one of whom progressed to a stage 11), one patient with a stage I1 ulcer, and two patients with stage 111 ulcers. Of the stage III pressure ulcer patients, two had suffered cerebrovascular accidents (CVAs) and one was a quadriplegic. Stage II patients included one with a CVA, one with a total knee replacement, and one with diagnoses of malnutrition, rigidity, and congestive heart failure. Stage I patients had diagnoses including spasticity, fracture with a hip prothesis, a CVA, and a craniotomy. In essence, all patients with a PU had debilitating physical conditions that limited mobility.
In these pressure ulcer positive (PU+) patients, 20% were incontinent of urine and 20% were incontinent of feces. There were 30% who had experienced a recent weight loss. Smoking and steroid use were not significant in the PU+ patients, nor were blood pressure readings. The most common overall location for the ulcers was the sacral area (3,followed by the elbows (3), right and left lateral malleolus ( I each), and the right and left heels ( I each) (see Table 2). The sacrum has been the most common site of pressure ulcers, as noted in research reported by Reuler and Cooney (1981) and Maklebust (1987). Nine of the 12ulcers (75%) were located at or below waist level, which is consistent with previous findings (Petersen & Bittmann, 1971; Versluysen, 1985). The pressure ulcer population ranged in age from 30 to 91 = 66 years old). The males = 67 years) were slightly older than the females = 65 years) on the average. Versluysen (1985) reported that 80% of all pressure ulcers occur in patients over age 70, and Gosnell(l989) noted that incidence rose with age. This is consistent with other studies found in the literature (Gosnell, 1989).
(x
(x
(x
Phase 2: The incidence study Procedure: All adult patients who consented verbally and were free of pressure ulcers were followed and assessed twice weekly for 4 weeks or until discharge. Ambulatory back patients and short-stay patients were eliminated. Subjects who hadparticipated in the prevalence study also were eliminated. Participants were assessed initially within 24 hours of adrnission to verify their being free of pressure ulcers. The Braden scale, a skin assessment, and a demographic data form were completed on each patient. In all instances, the Braden scale and the skin assessments were completed by two separate nurses caring for and/or familiar with the patient. The nurses were assigned to do only skin assessments or Braden scale scores to avoid bias and subjectivity. The Braden scores were placed in a sealed envelope and collected by the investigators to ensure secrecy and to avoid biasing the nurse conducting the skin assessment. Results: None of the40 patients who were followed developed any pressure ulcers during the 4-month period of the study. The incidence was 0%. Discussion: Why was there no incidence when the prevalence rate was 25%? Analysis of the patient population revealed that spinal cord injured patients do not come to this agency during the acute phase. The majority of patients in the agency had CVAs and prosthetic replacements and were transferred from an acute care hospital to the rehabilitation center for therapeutic treatment. Several of the reconstructive surgery patients stayed at the center less than 2 weeks. In thisrehabilitativesetting, thereisastrong, ongoing emphasis on skin care. Nurses assess the skin on admission and at least daily. This emphasis would appear to play a key factor in preventing pressure ulcers in this facility. While pressure ulcers have developed in the center, none developed for the sample studied in this particular time frame. It is interesting to note that five pressure ulcers (the majority being stage I) did develop after
Vol. 17, No. SRehabilitation Nursing/Sep-Oct 1992/241
Pressure Ulcer Prevalence and Incidence
admission, as seen during the prevalence audit; however, no pressure ulcers developed during the incidence study. The prevalence audit was important because it verified that pressure ulcers do occur in this rehabilitation setting and that patients areadmitted withulcers. Skincareis ahighpriority inthis institution, therefore accounting (at least in part) for the zero incidence. Since this study took place, protocols and staff education regarding pressure ulcers have been formalized, implemented, and evaluated to assess their effect on pressure ulcer occurrence. A recommended cutoff score for the Braden scale is included in the agency’s pressure ulcer protocols. The score was determined for this agency through the research process. Pressure ulcers do exist. Healthcare professionals have a significant responsibility to decrease the prevalence and incidence of pressure ulcers. Statistics in these areas should be gathered for each institution so that it can be determined if the prevalence rate indeed does decrease after a prevention program is instituted.
Recommendations for further research This study should be replicated in each rehabilitation facility that has not yet documented, via research, the prevalence and incidence of pressure ulcers in the facility. Baseline data are vital for the establishment of knowledge on the problem and for future comparative purposes. Quality assurance data can be enhanced greatly when research-based prevalence and incidence data are included. Accurate identification and documentation of patients at risk for pressure ulcer development are essential. Future research needs to be focused on the identification ofrisk factors and critical periods for pressure ulcer development specific to each rehabilitation facility’s patient population. Are risk factors the same for different stages of ulcers? Are the risk factors associated with specific medical and nursing diagnoses and consequent physical impairments more characteristic of one stage of pressure ulcer than of another? Early recognition and treatment for patients at risk are far less costly to the patient in terms of physical, psychological, and financial suffering.
Most of the authors are afJiliated with the UniversityofNorth Dakota College of Nursing in Grand Forks, ND: Susan Montgomery Hunter is an assistantprofessor, Diane K. Langemo is a professor, Bette Olson is an assistant professor, Darlene Hanson and Chris Burd are instructors, and Timothy R. Sauvage is director of the anesthesia nursing clinical specialization. Tressa Cathcart-Silberberg is a doctoral student at the University of Texas at Austin in Austin, TX.
References Allman, R. (1989). Epidemiology of pressure sores in different populations. Decubitus, 2(2), 30-33. Bergstrom, N., Braden, B., Laguzza, A., & Holman, V. (1987). The Braden scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. Bergstrom,N., Demuth, P., & Braden, B. (1987). A clinical trial of the
Braden scale for predicting pressure sore risk. Nursing Clinics of North America, 22(2), 417-428. Braden, B., & Bergstrom, N. (1989). Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus, 2(3), 44-51. Gaymar Industries, Inc. (1987). Total education and management of pressure ulcers: A guide to implementation. Orchard Park, NY: Gaymar Industries, Inc., and Lourdes Hospital. Gosnell, D.J. (1989). Pressure sore risk assessment: A critique-Part 11: Analysis of risk factors. Decubitus, 2(3), 40-43. Kerr, J., Stinson, S., & Shannon, M. (1981). Pressure sores: Distinguishing fact from fiction. The Canadian Nurse, 77(4), 23-28. Krouskop, T.A. (1983). A synthesis of the factors that contribute to pressure sore formation. Medical Hypotheses, 11,255-267. Levine, M. (1969). Introduction to clinical nursing. Philadelphia: F.A. Davis CompanyPublishers. Maklebust,J. (1987).Pressureulcers: Etiology and prevention. Nursing Clinics of North America, 22(2), 359-377. Mawson, A., Biundo, Jr., J., Neville, P., Linares, H., Winchester, Y., & Lopez, A. (1988). Risk factors for early occumng pressure ulcers following spinal cord injury.American Journal of Physical Medicine & Rehabilitation, 67(3), 123-127. NationalPressureUlcer Advisory Panel. (1989). Pressure ulcer prevalence, cost and risk assessment: Consensus development conference statement. Decubitus, 2(2), 24-28. Petersen, N.C., & Bittmann, S. (1971). The epidemiologyof pressure sores. Scandinavian Journal of Plastic Reconstruction and Surgery, 5,62-66. Reuler, J., & Cooney, T. (1981).The pressure sore: Pathophysiology and principles of management. Annals of Internal Medicine, 94, 66 1-666. Richardson, R., & Meyer, Jr., P. (1981). Prevalence and incidence of pressure sores in acute spinal cord injuries. Paraplegia, 19,235247. Shannon, L., & Skorga, P. (1989). Pressure ulcer prevalence in two general hospitals. Decubitus, 2(4), 38-43. Shea, J. (1975). Pressure sores: Classification and management. Clinical Orthopredicsand Related Research, 112,89-100. Staas, Jr., W., & LaMantia, J. (1982). Decubitus ulcers and rehabilitation medicine. International Journal of Dermatology, 21,437444. StandardsCommittee of the International Association for Enterostomal Therapy. (1988). Standards of care: Dermal wounds; pressure sores. Journal of Enterostomal Therapy, 15(1). 4-17. Versluysen, M. (1985). Pressure sores in elderly patients. Journal of Bone and Joint Surgery, 67(l), 10-13. Young, J.S., Bums, P.E., Bowen, A.M., & McCutchen, R. (1982). Spinal cord injury statistics: Experience of the regional spinal cord injury systems. Phoenix, AZ: Good Samaritan Medical Center.
Acknowledgments Special thanks are extended to Richard Landry, PhD, statistician; Diane Smith, BSN.RN CRRN; Theresa Bjorg, BSN RN CRRN; Rhonda Reimer, BSN RN CRRN; the University of North Dakota Medical Center Rehabilitation Hospital and Clinics in Grand Forks, ND; and all the administrators, staff nurses, and research nurse assistants who assisted with this research study. This research has been supported in part by Gaymar Industries, Inc., of Orchard Park, NY.
242/Sep-Oct 1992/Rehabilitation Nursing/Vol. 17, No. 5
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Vol. 17, No. S/Rehabilitation NursindSep-Oct 1992/243
I
t has been estimated that more than 1 million people in acute
care hospitals and nursing homes suffer from pressure ulcers (PU) (National Pressure Ulcer Advisory Panel [NPUAP], 1989). In spinal cord injured patients, the prevalence of pressure ulcers (how many patients in a given population have a pressure ulcer at any given time) ranges from 20% to 66% (Richardson & Meyer, 1981; Shannon & Skorga, 1989; Young, Bums, Bowen, & McCutchen, 1982). The incidence of pressure ulcers (how many patients develop a pressure ulcer over a specified period of time) ranges from 25% to 85% (Kerr,Stinson, &Shannon, 1981; Mawson et al., 1988; Richardson & Meyer, 1981; Staas & LaMantia, 1982; Young et al., 1982)and is highly dependent on the level of the injury and coexisting medical conditions.According to Reuler and Cooney (1981), 7% to 8% of spinal cord injured patients die from complications of pressure ulcers. In economic terms, Krouskop (1983) estimated that the cost of treating pressure ulcers in the United States, taking into account the loss of patient productivity,exceeds $2 billion annually.It has been estimated that $66 million is spent in annual hospitalization costs for newly injured spinal cord patients under treatment for pressure ulcers (Mawson et al., 1988). With such staggering amounts of money being spent on pressure ulcers-not to mention the suffering experiencedby the patients-a pressure ulcer prevention program to decrease the incidence, cost, and suffering experienced by the patients would be beneficial. In addition to decreasing financial burdens and personal suffering, a prevention program also could be used for quality assurance. With these ideas in mind, the authors undertook the study described here. Address correspondence to Susan Montgomery Hunter, MSN RN, Assistant Professor, University of North Dakota College of Nursing, PO Box 8195, University Station, Grand Forks, ND, 58202-8195.
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Rehabilitation Nursing is pleased to offer the opportunity to eam continuing education credit to those who read this article and complete the form immediately following it. This continuing education offering will provide 1contact hour to those who complete it appropriately. (See form for further details.)
Intended audience This independent study offering is appropriate for all rehabilitation nurses. Objectives By reading this article, the learner will achieve the following objectives: 1. Describe typical rates of pressure ulcer prevalence in rehabilitation patients and relate them to the rates revealed by this study. 2. Discuss the reasons for the discrepancy between the prevalence and incidence of pressure ulcers in this study. The study Purpose: The extent of a problem must be established before a prevention program can be implemented and later evaluated for success (Gaymar Industries, Inc., 1987). Therefore, the authors decided to conduct a study of pressure ulcer prevalence and incidence at a rehabilitation hospital in the Midwest to establish a baseline of the status of these problems for current and future comparative purposes. This research study consisted of two phases. Phase 1 focused on the prevalence of pressure ulcers (number of patients with a pressure ulcer at a given time) among patients in a rehabilitation setting. Phase 2 focused on the incidenceof pressure ulcers (number of persons developing pressure ulcers over a set time period) in a rehabilitative setting. A third phase (not documented here) focused on the prevalence of pressure ulcers in a rehabilitation setting after a formal prevention program was instituted. Theoretical framework: The theoretical framework used for this study was that of Levine’s (1969) “conservation of structural integrity” (p. 11). The theory of conservation of structural integrity is based on the process of therapeutic nursing interventions
Vol. 17, No. Smehabilitation NursindSep-Oct 1992/239
Pressure Ulcer Prevalence and Incidence
for restoration or maintenance of the body’s structure. When there is an unfavorable adaptation, pressure ulcers can develop quite rapidly. Supportive intervention, a concept from Levine’s theory, was applied in this study through the preservation or restoration of structural integrity, thereby conserving the resources of the individual. Definitions: In this study, pressure ulcers were defined as lesions on any skin surface that occur as a result of pressure; they include reactive hyperemia as well as blisters, broken skin, or necrotic tissue. Prevalence was defined as “the number or percentage of persons with a pressure ulcer at a given time in a particular population” (Allman, 1989, p. 3 1). Incidence was defined as “the number or percentage of persons at risk who have newly developed pressure ulcers after a certain period of followup” (Allman, 1989,p. 3 1).Thefollow-upperiod was a minimum of 1% weeks to 4 weeks or until discharge. Setting: The study took place in a 79-bed nonacute rehabilitation center in the Midwest. Patients were admitted to the hospital from home or transferred from community nursing homes or hospitals. Sample: All patients 18 years of age and older who consented were included in the prevalence and incidence studies. Ambulatory back patients and short-stay patients (those in the hospital for less than 1week) were not included in the incidence study. Forty patients participated in the prevalence study. Forty different patients participated in the incidence study. Instruments:Three instrumentswere used for datacollection. These consisted of a demographic data form, a skin assessment tool, and the Braden Scale for Predicting Pressure Sore Risk (Braden & Bergstrom, 1989). The demographic tool documented data such as age, sex, diagnosis, height and weight, vital signs, activity, steroidtherapy, and smoking history. These variables were used for correlation with the prevalence and incidence of pressure ulcers. The skin assessment tool contained the definition of pressure ulcers used in the study and a full body diagram detailing all sites to be assessed. Each site was assessed and rated. The rating scales used Shea’s (1975) four stages of pressure ulcers and the standards of care for pressure ulcers developed by the International Association for Enterostomal Therapy (Standards Committee of the International Association for Enterostomal Therapy [IAET], 1988). A zero meant no redness or breakdown, while a stage I meant nonblanchable erythema, and a stage IV was a skin break extending into the subcutaneous and muscle layers. All subjects were assessed and rated systematically. Body moisture also was assessed, including urinary and fecal incontinence. The Braden Scale for Predicting Pressure Sore Risk is a summative rating scale consisting of six subscales that reflect the “critical determinantsof pressure (mobility, activity, and sensory perception) and factors influencing the tolerance of the skin and supporting structures for pressure (skin moisture, nutritional status, and friction and shear)” (Bergstrom, Demuth, & Braden, 1987, p. 417). The maximum total score is 23. Each level of the scale is mutually exclusive. The lower the scale score, the higher the risk. Interrater reliability has been reported as 88% for RNs
(r = .99) and 11% to 19% for LPNs and nurse aides (r = 27) (Bergstrom, Braden, Laguzza, & Holman, 1987). The Braden scale was used to assess data on six subscales, to acquaint staff in agencies with the tool, and toestablish mean scores for the agency patients. The interrater reliability for RNs in this setting was .98 (percent of agreement) after education sessions on the use of the Braden scale. This was obtained by having two nurses who cared for a patient independentlycomplete the Braden scale and, if the scores varied by more than one point, having a third person complete the Braden scale to establish consensus.
Table 1. Number (Prevalence) of Pressure Ulcers in a Rehabilitation Setting
(A/=40; 22 males, 18 females) Stage
I II Ill
IV
#of Males 2 1 1 0
#of #of #of PUS Females PUS 2 2 3 1 2 3 1 2 2 0
10 25 12
4 18 4
6 33 8
5
3
2
5
3
2
Total Patients 4 3 3 0
Number positive Percent positive Number of ulcers Number admitted with ulcers Number who developed ulcers after admission
Phase 1: The prevalence study Procedure: The researchers and the RN research assistants completed systematic skin assessments of all patients who verbally consented. For each patient found to have a pressure ulcer in any stage (I to IV),a demographicdata form was completed by the researchers and a Braden scale rating was done independently by twonurses whoknew the patient but who hadnot done the skin assessment (to prevent rater bias). All patients were assessed on a single day. Data analysis: Descriptive statistics were obtained using the Statistical Package for Social Sciences (SPSS). Results: From a sample of 40 patients, 10 (25%) were found to have pressure ulcers (see Table 1).Two patients had two ulcers each for a total of 12 ulcers. Five pressure ulcers were in stage I, four were in stage LI, and three were in stage III. The sizes of the ulcers varied from 0.5 cm x 0.5 cm to 16 cm x 8 cm. The 16 cm x 8 cm ulcer was a stage I. The majority were 4 cm x 4 cm in size. For patients who had pressure ulcers, the Braden scale scores ranged from 11 to 19 points with a mean of 14.
240/Sep-Oct 1992/Rehabilitation NursingNol. 17, No. 5
Discussion: This study used Shea’s (1975) classification of pressure ulcer stages and the IAET’s standards of care for pressure ulcers (Standards Committee of the IAET, 1988) and was consistent with the National Pressure Ulcer Advisory Panel (NPUAP)’sconsensus statementonpressureulcers (1989). Stage I includes nonblanchable erythema of intact skin. Stage I1 is a partial thickness skin loss. Stage 111consists of full-thickness skin loss extending down to the fascia. Subcutaneous fat is exposed. Stage IV exposes muscle and bone. Some studies have been very inconsistent in including reddened areas without skin breaks as
Table 2. Pressure Ulcer Location Stage
Total Number of Ulcers
Site
I I I
2 2 1
Both heels Sacral Right lateral malleolus
II II
2 2
Left elbow Sacral
Ill Ill Ill
1 1 1
Left lateral rnalleolus Sacral Left elbow
positive stage I ulcers. With the international acceptance of the NPUAP consensus conference definitions of stages I to IV, it is anticipated that this research problem should be eliminated. As has been stated previously, prevalence rates in rehabilitation patients can range from 20% to 66%. The prevalence rate for this study was low in comparison to rates found in previous research. If the five pressure ulcers in stage I were eliminated, which has been done in many previous studies, the prevalence rate would be 15%, which is well below the usual prevalence rates. Five of the 10patients who had pressure ulcers developed them after being admitted to the facility (see Table 1). Three of these patients had stageIulcers, onehadastageIIulcer(whichoccurred on the 15th day after admission), and one had a stage 111 ulcer (which occurred approximately 4% months prior to the audit). Those who were admitted with a pressure ulcer included two patients with stage1ulcers (one of whom progressed to a stage 11), one patient with a stage I1 ulcer, and two patients with stage 111 ulcers. Of the stage III pressure ulcer patients, two had suffered cerebrovascular accidents (CVAs) and one was a quadriplegic. Stage II patients included one with a CVA, one with a total knee replacement, and one with diagnoses of malnutrition, rigidity, and congestive heart failure. Stage I patients had diagnoses including spasticity, fracture with a hip prothesis, a CVA, and a craniotomy. In essence, all patients with a PU had debilitating physical conditions that limited mobility.
In these pressure ulcer positive (PU+) patients, 20% were incontinent of urine and 20% were incontinent of feces. There were 30% who had experienced a recent weight loss. Smoking and steroid use were not significant in the PU+ patients, nor were blood pressure readings. The most common overall location for the ulcers was the sacral area (3,followed by the elbows (3), right and left lateral malleolus ( I each), and the right and left heels ( I each) (see Table 2). The sacrum has been the most common site of pressure ulcers, as noted in research reported by Reuler and Cooney (1981) and Maklebust (1987). Nine of the 12ulcers (75%) were located at or below waist level, which is consistent with previous findings (Petersen & Bittmann, 1971; Versluysen, 1985). The pressure ulcer population ranged in age from 30 to 91 = 66 years old). The males = 67 years) were slightly older than the females = 65 years) on the average. Versluysen (1985) reported that 80% of all pressure ulcers occur in patients over age 70, and Gosnell(l989) noted that incidence rose with age. This is consistent with other studies found in the literature (Gosnell, 1989).
(x
(x
(x
Phase 2: The incidence study Procedure: All adult patients who consented verbally and were free of pressure ulcers were followed and assessed twice weekly for 4 weeks or until discharge. Ambulatory back patients and short-stay patients were eliminated. Subjects who hadparticipated in the prevalence study also were eliminated. Participants were assessed initially within 24 hours of adrnission to verify their being free of pressure ulcers. The Braden scale, a skin assessment, and a demographic data form were completed on each patient. In all instances, the Braden scale and the skin assessments were completed by two separate nurses caring for and/or familiar with the patient. The nurses were assigned to do only skin assessments or Braden scale scores to avoid bias and subjectivity. The Braden scores were placed in a sealed envelope and collected by the investigators to ensure secrecy and to avoid biasing the nurse conducting the skin assessment. Results: None of the40 patients who were followed developed any pressure ulcers during the 4-month period of the study. The incidence was 0%. Discussion: Why was there no incidence when the prevalence rate was 25%? Analysis of the patient population revealed that spinal cord injured patients do not come to this agency during the acute phase. The majority of patients in the agency had CVAs and prosthetic replacements and were transferred from an acute care hospital to the rehabilitation center for therapeutic treatment. Several of the reconstructive surgery patients stayed at the center less than 2 weeks. In thisrehabilitativesetting, thereisastrong, ongoing emphasis on skin care. Nurses assess the skin on admission and at least daily. This emphasis would appear to play a key factor in preventing pressure ulcers in this facility. While pressure ulcers have developed in the center, none developed for the sample studied in this particular time frame. It is interesting to note that five pressure ulcers (the majority being stage I) did develop after
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Pressure Ulcer Prevalence and Incidence
admission, as seen during the prevalence audit; however, no pressure ulcers developed during the incidence study. The prevalence audit was important because it verified that pressure ulcers do occur in this rehabilitation setting and that patients areadmitted withulcers. Skincareis ahighpriority inthis institution, therefore accounting (at least in part) for the zero incidence. Since this study took place, protocols and staff education regarding pressure ulcers have been formalized, implemented, and evaluated to assess their effect on pressure ulcer occurrence. A recommended cutoff score for the Braden scale is included in the agency’s pressure ulcer protocols. The score was determined for this agency through the research process. Pressure ulcers do exist. Healthcare professionals have a significant responsibility to decrease the prevalence and incidence of pressure ulcers. Statistics in these areas should be gathered for each institution so that it can be determined if the prevalence rate indeed does decrease after a prevention program is instituted.
Recommendations for further research This study should be replicated in each rehabilitation facility that has not yet documented, via research, the prevalence and incidence of pressure ulcers in the facility. Baseline data are vital for the establishment of knowledge on the problem and for future comparative purposes. Quality assurance data can be enhanced greatly when research-based prevalence and incidence data are included. Accurate identification and documentation of patients at risk for pressure ulcer development are essential. Future research needs to be focused on the identification ofrisk factors and critical periods for pressure ulcer development specific to each rehabilitation facility’s patient population. Are risk factors the same for different stages of ulcers? Are the risk factors associated with specific medical and nursing diagnoses and consequent physical impairments more characteristic of one stage of pressure ulcer than of another? Early recognition and treatment for patients at risk are far less costly to the patient in terms of physical, psychological, and financial suffering.
Most of the authors are afJiliated with the UniversityofNorth Dakota College of Nursing in Grand Forks, ND: Susan Montgomery Hunter is an assistantprofessor, Diane K. Langemo is a professor, Bette Olson is an assistant professor, Darlene Hanson and Chris Burd are instructors, and Timothy R. Sauvage is director of the anesthesia nursing clinical specialization. Tressa Cathcart-Silberberg is a doctoral student at the University of Texas at Austin in Austin, TX.
References Allman, R. (1989). Epidemiology of pressure sores in different populations. Decubitus, 2(2), 30-33. Bergstrom, N., Braden, B., Laguzza, A., & Holman, V. (1987). The Braden scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. Bergstrom,N., Demuth, P., & Braden, B. (1987). A clinical trial of the
Braden scale for predicting pressure sore risk. Nursing Clinics of North America, 22(2), 417-428. Braden, B., & Bergstrom, N. (1989). Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus, 2(3), 44-51. Gaymar Industries, Inc. (1987). Total education and management of pressure ulcers: A guide to implementation. Orchard Park, NY: Gaymar Industries, Inc., and Lourdes Hospital. Gosnell, D.J. (1989). Pressure sore risk assessment: A critique-Part 11: Analysis of risk factors. Decubitus, 2(3), 40-43. Kerr, J., Stinson, S., & Shannon, M. (1981). Pressure sores: Distinguishing fact from fiction. The Canadian Nurse, 77(4), 23-28. Krouskop, T.A. (1983). A synthesis of the factors that contribute to pressure sore formation. Medical Hypotheses, 11,255-267. Levine, M. (1969). Introduction to clinical nursing. Philadelphia: F.A. Davis CompanyPublishers. Maklebust,J. (1987).Pressureulcers: Etiology and prevention. Nursing Clinics of North America, 22(2), 359-377. Mawson, A., Biundo, Jr., J., Neville, P., Linares, H., Winchester, Y., & Lopez, A. (1988). Risk factors for early occumng pressure ulcers following spinal cord injury.American Journal of Physical Medicine & Rehabilitation, 67(3), 123-127. NationalPressureUlcer Advisory Panel. (1989). Pressure ulcer prevalence, cost and risk assessment: Consensus development conference statement. Decubitus, 2(2), 24-28. Petersen, N.C., & Bittmann, S. (1971). The epidemiologyof pressure sores. Scandinavian Journal of Plastic Reconstruction and Surgery, 5,62-66. Reuler, J., & Cooney, T. (1981).The pressure sore: Pathophysiology and principles of management. Annals of Internal Medicine, 94, 66 1-666. Richardson, R., & Meyer, Jr., P. (1981). Prevalence and incidence of pressure sores in acute spinal cord injuries. Paraplegia, 19,235247. Shannon, L., & Skorga, P. (1989). Pressure ulcer prevalence in two general hospitals. Decubitus, 2(4), 38-43. Shea, J. (1975). Pressure sores: Classification and management. Clinical Orthopredicsand Related Research, 112,89-100. Staas, Jr., W., & LaMantia, J. (1982). Decubitus ulcers and rehabilitation medicine. International Journal of Dermatology, 21,437444. StandardsCommittee of the International Association for Enterostomal Therapy. (1988). Standards of care: Dermal wounds; pressure sores. Journal of Enterostomal Therapy, 15(1). 4-17. Versluysen, M. (1985). Pressure sores in elderly patients. Journal of Bone and Joint Surgery, 67(l), 10-13. Young, J.S., Bums, P.E., Bowen, A.M., & McCutchen, R. (1982). Spinal cord injury statistics: Experience of the regional spinal cord injury systems. Phoenix, AZ: Good Samaritan Medical Center.
Acknowledgments Special thanks are extended to Richard Landry, PhD, statistician; Diane Smith, BSN.RN CRRN; Theresa Bjorg, BSN RN CRRN; Rhonda Reimer, BSN RN CRRN; the University of North Dakota Medical Center Rehabilitation Hospital and Clinics in Grand Forks, ND; and all the administrators, staff nurses, and research nurse assistants who assisted with this research study. This research has been supported in part by Gaymar Industries, Inc., of Orchard Park, NY.
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