A Four Year Review of Pressure Ulcer Prevalence

Clarissa Young and Fiona Stoker

Abstract
Prevalence and incidence surveys have been used to demonstrate the number and stages of pressure ulcers for over 20 years. Pressure ulcer point prevalence and incidence study results generated over a 4 year period at the Launceston General Hospital (LGH) will be presented and discussed. The reliability of both prevalence and incidence as a measure will be discussed in relation to the rates recorded as well as general data interpretation. Benefits of prevalence and incidence surveys as presented by Dealey will form the criteria used to assess the four consecutive annual point prevalence surveys undertaken at the LGH since 1996.

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A Pressure Ulcer Survey Conducted at a Private Hospital

Shauna Eves

Summary
Pressure ulcers pose a significant problem for every health care institution. They are a serious threat to the patient and significantly drain hospital resources. Many health care institutions throughout the world have recognised and investigated the extent of this problem and subsequently have devised strategies to reduce the problem.
In Australia, it is widely acknowledged that health care professionals have an obligation to regularly review the care and services they provide and, where necessary, to change clinical practice to ensure they achieve best outcomes for patients.  Pressure ulcer surveillance is seen by some Australian hospitals as an important exercise in quality review. Surveys in these hospitals have been conducted in order to determine the prevalence and severity of pressure ulcers and audit existing pressure relieving devices.
The Nursing Practice and Research Council at St John of God Health Care, Subiaco (SJOGHCS), Perth, Western Australia, proposed the first pressure ulcer prevalence surrey be conducted at this hospital in March 1998. This was to determine the prevalence and severity of pressure ulcers in the hospital’s inpatient population. This information would assist us to evaluate the impact of recently implemented strategies for pressure ulcer management; in particular the hospitals pressure ulcer risk assessment scale. Before this survey, no pressure ulcer prevalence surveys had ever been conducted at this hospital or at any other hospital within the St John of God Health Care Australian network of hospitals. The author is unaware of any published results of pressure ulcer prevalence surveys that may have been conducted in other private hospitals in Western Australia.
On 8 March 1998, 234 patients had their skin examined for evidence of pressure ulcers to identify their prevalence. This was found to be 10.6 per cent. In addition to the prevalence, accumulative incidence and risk were reported, together with accurate information on the number and types of pressure relieving devices being used on the wards, At the same time, a ‘pink dot protocol' was introduced to identify and alert the nurses to those patients at high risk of developing pressure ulcers.
Following the survey, recommendations regarding pressure reducing/relieving equipment, in-service education and a mattress replacement program were made. It was also recommended that the pressure ulcer prevalence survey be repeated again in 12-18 months' time. This paper will discuss and report on the results and recommendations of the first pressure ulcer prevalence survey conducted at SJOGHCS, Perth, Western Australia.

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The Influence of Iron and Free Radicals on Chronic Leg Ulceration

Sim Yeoh

Summary
It has been well established that ambulatory venous hypertension and accompanying chronic inflammation cause a major alteration in tissue and ultimately skin ulceration. In spite of considerable advances made in venous ulcer research, the underlying pathophysiology of chronic venous leg ulceration and the failure to heal is not completely understood. Currently there is considerable clinical and scientific research into the role of inflammatory and tissue cells and their mediators in wound repair. Few studies have addressed the possible contribution of free radical production to venous ulceration and little has been done to examine the role of iron in initiating and/or perpetuating tissue damage in venous ulceration. Interest in the role of iron in venous ulceration has come with increasing evidence implicating free radical generation by iron in other chronic inflammatory and iron– overload diseases. Conditions such as chronic inflammation, tissue ischaemia, activation of neutrophils and high levels of localised iron in the tissues are conducive to the generation of free radicals in venous disease. It is possible that iron may participate in tissue damage in a similar manner in which it does in other inflammatory disorders. However, this remains to be elucidated.

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Venous Thromboembolism: An Insidious Hazard
Part 1: Incidence, Prevalence and Sequelae

Donald G. MacLellan M.D., F.R.A.C.S

Summary
Venous ulceration continues to be a significant cause of a poor quality of life for patients and a major burden on the Australian health dollar. It is estimated to cost $300-500 million per annum to manage. Prevention of deep venous thrombosis (DVT) and the consequent chronic venous insufficiency (CVI) would have a major impact on the prevalence of venous ulcers. This review examines the incidence of DVT and pulmonary embolism (PE) in the community and determines the consequences of CVI and ulceration. Clinicians are encouraged to consider prophylaxis for this insidious condition.

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The Use of Antiseptics in Wound Management: A Community Nursing Focus

Pam Selim

Summary
The increased focus on research and evidence for practice has seen changes in wound management practice. In the community, district nurses now, more than ever, want to control and own their wound management practice. The increased awareness of evidence based wound management practice has, however, caused conflict with some medical colleagues. Some district nurses have been asked to defend their wound management practice. The evidence from this review highlights considerations that need to be taken into account when using antiseptics, particularly povidone iodine. Povidone iodine has use as a skin preparation and for the management of burns, however, it is ineffective in the presence of body fluids, is toxic to fibroblasts and not recommended for prolonged use. Effective use of povidone iodine requires frequent dressing changes and, in the community setting, this is not best wound management practice. Other cleansing options are briefly discussed and the paper highlights the considerable debate regarding the effectiveness and safety of antiseptics.

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Selection of Honey for Use as a Wound Dressing

P C Molan BSc PhD

Summary
The use of honey as a dressing material for infected wounds is becoming of increasing interest as more reports of its effectiveness are published and as alternative treatments are sought for wounds infected with antibiotic-resistant strains of pathogens. But there appears to be a general lack of awareness of the very large variation that is found in the potency of the antibacterial activity of honey, which may explain the differences reported in the speed of clearance of infection from wounds dressed with honey.
Mostly, the antibacterial activity of honey is due to enzymically generated hydrogen peroxide, which is decreased by exposure of the honey to heat or light during processing or storage, or inactivated by substances in the nectar from some plants. In addition to this, there are non-peroxide antibacterial substances from the nectar of certain plants. These are usually only minor components, but in some honeys from some Leptospermum species (manuka and jellybush) there is a high level of non-peroxide antibacterial activity. This may be significant clinically, as the catalase activity present in wounds has the potential to inactivate the hydrogen peroxide produced in honey. In the absence of data from a comparative clinical trial, the rational approach to selecting a honey for use in wound care would be to choose a honey with a high level of both hydrogen peroxide and non-peroxide antibacterial activity. Because there is such a marked variation in honeys, even within a floral type, laboratory testing is necessary to establish the antibacterial potency.

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Plantar Heel Pressure Relief from the MPO Active 2000® Ambulatory Splint*

Geraldine Glanville and Craig Payne

Summary
Heel ulcers are a significant and costly problem that require pressure relief for healing. The MPO Active 2000 ® splint was designed to provide both ambulatory and in-bed pressure relief for heel ulcers to facilitate repair. The aim of this study was to determine the pressure reduction under the foot during ambulation using the MPO Active 2000 splint. Fifteen healthy volunteers (mean age 22 years) were recruited. Pressure under the heel during ambulation was measured both in plain canvas shoes and with the MPO Active 2000 splint. The Novel Pedar TM in-shoe plantar pressuring measuring system was used. Peak pressure under the heel wearing the MPO Active 2000 splint was 17 per cent less than in the shoes – 269.3Kpa (±47.4) vs 224Kpa (±39); p<0.01. There was no change in forefoot pressure– 296.0Kpa(±69) vs 287.3 (±101); p=0.79. The MPO Active 2000 splint should be considered as a modality to reduce heel pressure in patients with heel ulcers.

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The role of sheepskins in preventing pressure ulcers in elderly orthopaedic patients

Sunita McGowan RN MAppSc(Nurs) FRCNA
Ken Montgomery BSc PhD Leeds
Damien Jolley MSc London MSc LaTrobe
Robyn Wright RN BAppSc(Nurs) GDipAppSc(ISM)

Summary
A randomised controlled trial was undertaken in the orthopaedic ward at two hospitals to estimate the efficacy of a newly developed Australian Medical Sheepskin overlay to prevent hospital acquired pressure ulcers relative to a standard hospital mattress or other low technological constant pressure supports. A total of 297 patients aged 60 years and above were randomised to receive the sheepskin overlay (experimental group) or the standard hospital mattress, with or without other low technological constant pressure supports (control group). At risk status for developing an ulcer was assessed daily using the Braden Scale. Patients were assessed for evidence of a pressure ulcer on a daily basis. The risk ratio for development of at least one pressure ulcer for the 155 patients in the experimental group and 142 control group was 0.30 (95% confidence interval 0.17 to 0.52). The hazard ratio for time to development of first pressure ulcer in the experimental group relative to control group was 0.31 (0.17 to 0.58). These results provide evidence that the Australian Medical Sheepskin is effective in preventing pressure ulcers in elderly orthopaedic patients. A more comprehensive investigation, concentrating particularly on the effect of the sheepskin on duration of stay in hospital, is indicated.

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The clinical contamination of amorphous hydrogels

Peter S. Aras, B.Pharm & Geoff Sussman, Ph.C MPS AFAIPM

Summary
Amorphous hydrogel products are commonly used in wound management practice in the treatment of shallow to full thickness open wounds. Whilst some of the products currently used in clinical practice are intended for single use only, they are often re-used in the interests of reducing costs and wastage, despite the potential risk of contamination in re-used products. In this study, packs of Intrasite GelTM, SolugelTM and Duoderm Hydroactive GelTM were re-used in the clinic over a 1 month period. Samples were qualitatively analysed for microbial contamination each week.
Flasks containing fluid casein soy lecithin polysorbate-20 (FCSLP-20) medium were inoculated with used hydrogel samples and incubated overnight. Flasks displaying ‘growth’ were subcultured onto selective media for preliminary identification of the contaminating organism(s). One ‘no growth’ flask from each product sample was subcultured onto nutrient agar to confirm the absence of contamination. Microbial contamination was absent in samples of each product during the 1 month period. Control strains were successfully grown in flasks and isolated on selective media. Negative control flasks showed ‘no growth’.
The ‘single use only’ packs of SolugelTM, IntrasiteTM Gel and Duoderm Hydroactive GelTM amorphous hydrogels were free of microbial contamination during product re-use in this study, despite use in an active wound clinic situation. This study highlights the need to review the use of these hydrogels and address the safety in the re-use of these products.

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A study on the incidence of pressure ulcers in the acute orthopaedic setting

Ms Jeanne Young, RN, BSc (Hons), Ms Pam Morey RN, BN, Ms Regina Browne RN, ENB 219
& Dr Sue Nikoletti RN, PhD

Abstract
As there is a paucity of literature on pressure ulcer incidence in the Australian context, this prospective cohort study was undertaken to determine the incidence of pressure ulcers in a group of orthopaedic patients in an acute care setting. All orthopaedic patients who were free of pressure ulcers on admission and who met the study criteria were invited to participate. Each patient then underwent second daily skin integrity assessments and Braden Scale reviews until discharge.
Ninety patients were invited to participate over a 6 week period, with 100 per cent recruitment achieved. The majority of patients underwent hip or knee surgery and the incidence of pressure ulcers for this group was calculated at 11 per cent (n=10). Fifty per cent of these patients developed a Stage one pressure ulcer that was present on at least two consecutive assessments, while the remainder of the sample developed Stage two pressure ulcers. Ninety per cent of pressure ulcers were located on the heel or sacrum, with the remainder found on the elbow. The majority of patients (n=7) developed their pressure ulcers between days 3-4 post-admission. All patients who developed a Stage two pressure ulcer were found to be on Vaperm mattresses rather than on alternating air mattress or static air overlay as recommended by hospital guidelines for use of therapeutic support surfaces.
Although the Braden Scale for the total group was found to have a high specificity (91 per cent), its sensitivity was low (40 per cent). Of the 10 patients who developed pressure ulcers, only one patient was assessed as being at high risk, three were assessed at a moderate risk, two patients at low risk and the remainder (n=4) were all assessed as being at no risk of developing a pressure ulcer. Subjects who acquired pressure ulcers were found to be significantly older when compared to the rest of the sample population (mean age 80 years, vs 68 years). Those with pressure ulcers stayed in hospital 2.1 times longer (13.5 days compared to 6.5 days) than the remainder of the study sample who had undergone similar surgical operation/procedures. In view of the lack of Australian data on the incidence of pressure ulcers in acute care settings, further studies using larger samples are warranted to establish national benchmarks and determine risk factors for pressure ulcer development.

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