Pressure Ulcer Incidence and Risk Factors Among Hospitalized Orthopedic Patients: Results of a Prospective Cohort Study

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1 FEATURE Pressure Ulcer Incidence and Risk Factors Among Hospitalized Orthopedic Patients: Results of a Prospective Cohort Study Jan Noel D. Molon, MD; and Emmanuel P. Estrella, MD Astract A variety of pressure ulcer (PU) risk factors has een identified, ut not all information is consistent and some applies to specific patient populations only. The purpose of this prospective cohort study was to assess the incidence of and ascertain potential risk factors for PU formation among hospitalized orthopedic patients in the Philippines. All patients consecutively admitted to an orthopedic ward of a tertiary hospital etween March 1 and Octoer 31, 2009 were eligile to participate if they were >19 years of age and expected to e confined to a ed or chair for at least 5 days while hospitalized. Eligile patients were seen within 48 hours following admission, and after providing informed consent, patient demographic variales, laoratory values, and other potential risk factors were recorded, including the presence of nonlanchale erythema or dry skin and Braden Risk Assessment Scale variales (sensory perception, moisture, activity, moility, nutrition, friction shear). The total Braden Risk Score was calculated and dichotomized to at risk (low, medium, high risk) and not at risk. Susequent skin inspections for the development of a Stage II or greater ulcer occurred weekly. Of the 256 persons admitted, 43 met the inclusion criteria and 40 (31 men and nine women) agreed to participate in the study. Eight patients developed an ulcer a median of 7 days after admission for an overall incidence of 20%; seven ulcers were Stage II, and one ulcer progressed to Stage III. The only significant difference etween patients who did and did not develop a PU was the presence of constant moisture (P <0.008) and impaired sensory perception (P <0.0001). The odds ratio (OR) for sensory perception was 45 (95% CI: , P = ) and for constant moisture was 10.8 (95% CI: , P = 0.008). On multivariate analysis, the adjusted OR was 43 (95% CI: ) for sensory perception and 10 (95% CI: ) for moisture. The likelihood ratio test showed that oth impaired sensory perception and constant moisture were predictive of PU formation (P = ). Most (six out of eight) patients who developed a PU had a history of spinal cord injury. Study results confirm that limited sensory perception and the presence of constant moisture are risk factors for PU development among hospitalized orthopedic patients. This is the first PU incidence and risk factor study conducted in the Philippines, and the results confirm some of those reported from orthopedic patient studies in other countries. Keywords: prospective study, incidence, pressure ulcers, risk factors, orthopedic patients Index: Ostomy Wound Management 2011;57(10):64 69 Potential Conflicts of Interest: none disclosed Pressure ulcers (PU) occur as a consequence of prolonged skin contact against a surface, whether the patient is in a recument or prone position 1-4 ; they are among the most common complications in healthcare. Reported incidence varies, 5 ut usually ranges from 0.4% to 38% in acute care settings and from 2.2% to 23.9% in chronic care facilities. 1 Numerous studies to investigate the factors predictive of PU formation have een conducted Among these risk factors, impaired moility or limited activity was found to e the most important Populations at risk for PU include the elderly, persons with spinal cord injury or other neurological deficits or degenerative processes, trauma patients, and persons with any condition that limits the aility to move Dr. Molon is a senior orthopedic resident and Dr. Estrella is a Clinical Associate Professor, Microsurgery Unit, Department of Orthopedics, UP-College of Medicine, Philipinne General Hospital; and Advanced Study and Research in Orthopedics (ASTRO) Study Group, National Institutes of Health (NIH), University of the Philippines-Manila, Manila, Philippines. Please address correspondence to: Emmanuel Estrella, MD, Microsurgery Unit, Department of Orthopedics, Philippine General Hospital, UP Manila, Manila, Philippines 1000; estee96@yahoo.com. 64 OSTOMY WOUND MANAGEMENT OCTOBER

2 PRESSURE ULCERS IN ORTHOPEDIC PATIENTS freely in response to the perception of discomfort. 3 Specific supopulations have een reported to have a high prevalence of PUs: hospitalized quadriplegics, elderly patients with femoral fractures, and patients in critical care units. 5 The presence of PU in these populations was found to e a risk factor for poor overall prognosis and premature mortality in some patients, 14 decreased quality of life, 15 frequent and longer hospital admissions, and more intensive nursing and medical care, as well as a sustantial urden to the healthcare system. 15,16 These studies show that PUs in admitted patients result in a poorer prognosis, premature mortality, longer hospital stay, and increased costs. At present, no data are availale regarding the prevalence of PU and the costs of treatment in the Philippines. In 2001, the average cost of treating PU in the US ranged from $5,000 to $70,000 depending on PU stage. The total national cost in the US for treatment was estimated to e $1.3 illion annually and rising. 15 A recent study 17 in nursing and residential facilities showed that estalishing a PU quality improvement collaorative (QIC) resulted in a decreased PU incidence and improved patient quality of life. Similar studies showed that a multidisciplinary 18 or a collaorative 19 approach may decrease PU incidence. However, the long-term cost effectiveness of implementing the QIC for PU prevention is still not known. 17 The Braden Risk Assessment Scale generally has een found to e a valid and reliale predictor of PU development. 6,7,20,21 The scale comprises six suscales that reflect sensory perception, skin moisture, activity, moility, friction and shear, and nutritional status. Results of a recent study 22 among 233 elderly patients indicate the scale has a sensitivity of 74.1% and a specificity of 75.4%. Because the treatment of estalished PUs is difficult and costly, the general recommendation from the literature was that use of a risk assessment scale always should e supplemented y a targeted preventive approach. 13 The purpose of this prospective cohort study was to determine if the following risk factors were associated with the occurrence of PUs among hospitalized orthopedic patients: the presence of nonlanchale erythema, Braden Scale score parameters (sensory perception, moility, activity, nutrition, moisture, and friction shear), and dry skin. Methods Patients. This study comprised a prospective cohort of all patients admitted to the orthopedic ward of a tertiary acute care hospital etween March 1, 2009 and Octoer 31, The protocol was approved y the Institutional Review Board of the hospital. The ward nurses were informed of the study y the investigators, and a research assistant (a registered nurse with at least 1 year of experience with patient care in a hospital setting) identified Ostomy Wound Management 2011;57(10):64 69 Key Points Researchers recorded pertinent patient information and assessed potential pressure ulcer risk factors of 40 patients admitted to an orthopedic ward for a minimum of 5 days. Twenty (20) percent of patients developed a Stage II or greater ulcer. In this patient population, limited sensory perception and the presence of moisture were independent risk factors for pressure ulcer development. potential study participants y visiting the wards three times a week or after eing informed y nursing staff that an eligile patient had een admitted during the past 48 hours. Inclusion criteria for the study were: patients 19 years old who expected to e confined to chair or ed for at least 5 days and expected to e hospitalized for at least 5 days. Persons admitted with a Stage II or greater PU 23 or active skin disease that would interfere with PU assessment were not eligile to participate. Upon admission to the orthopedic ward, all patients were placed on a standard mattress and a standard turning protocol (every 2 to 3 hours) was implemented for all admitted patients with limited moility. Once a participant was determined to e eligile for the study, the research assistant provided him/her a copy of the informed consent document. Study variales. At study aseline (following admission), demographic variales, including patient age, gender, height, weight, and ody mass index, and laoratory findings (lymphocyte count and alumin levels), were recorded. The research assistant assessed the following: presence of nonlanching erythema (skin with localized nonlanchale redness over a ony prominence upon depression) and dry skin (a paucity of moisture or the presence of scaling over a ony prominence). Bony prominences included occipital, scapular, spinal, sacral, trochanteric, ankle, and heel areas. Braden Risk Assessment Scale parameters (sensory perception, activity, moisture, moility, nutrition, and friction shear) were assessed; participants were categorized as at risk (score of 18) or not at risk (score of >19). 22 A score of 18 was the cut-off value for the risk assessment. The research assistant assessed the skin over all ony prominences of enrolled participants two times a week until discharge for a maximum of 8 weeks. Standard care protocols, including wound dressing and/or deridement, were initiated when a Stage II or greater PU was identified. Outcomes evaluation. PUs were defined as epithelial loss or skin reakdown over a ony prominence 2,23 and OCTOBER 2011 OSTOMY WOUND MANAGEMENT 65

3 FEATURE Tale 1. Patient demographic characteristics and study aseline variales y pressure ulcer outcome Average (SD) age (years) Lymphocyte count average (SD) Serum alumin Average, SD (g/l, SD) No pressure ulcer (n = 32) Pressure ulcer (n = 8) 38.5 (16.8) 40.5 (15.5) (0.06) 0.16 (0.7) (5.3) 30 (4.4) 0.47 Weight (kg, SD) 59.7 (11.5) 58.8 (9.3) 0.84 Height (m, SD) 1.64 (0.7) 1.64 (0.7) 0.75 Body mass index 22.1 (4.7) 22 (3.4) 0.95 SD = standard deviation were graded according to the European Pressure Ulcer Advisory Panel. 23 The primary outcome or endpoint in this prospective study was the occurrence of a Stage II or greater PU. Data analysis. Data were encoded using Microsoft Excel 2007 and EpiInfo version (Atlanta, GA) for Windows and analyzed using EpiInfo for Windows and STAT version 10.0 (College Station, TX). Continuous data were expressed as means and standard deviations. Categorical data were expressed as frequencies for populations with and without pressure ulcers. The t-test and the Fisher s exact test were used to determine whether a difference was found etween the demographic factors and eight hypothesized risk factors of persons who did and did not develop PUs. To determine which variales were predictors for PU formation, each hypothesized risk factor was analyzed using a crude logistic regression analysis with 95% confidence intervals (CI) in which a P value of <0.10 was considered significant. Significant factors on crude analysis were included in the multiple regression analysis using the hierarchical method of selection with a P value of 0.05 set for statistical significance. Results Demographic characteristics. Of the 256 persons admitted in the 8-month study period, 43 were eligile for inclusion. The majority of patients had an average hospital stay of >14 days. Most of the patients (four out of eight) who developed PUs were 24 to 33 years of age. Three (3) of the 43 eligile patients did not want to provide informed consent. Of the 40 remaining participants (31 men and nine women), eight developed a Stage II or greater PU P value for a total incidence of 20%; of the 31 men, six developed PU (P = 0.59) and of the nine women, two developed PU (P = 0.59), all in the sacral area. The median time for PU development was 7 days. Seven people developed Stage II and one developed Stage III PUs. More patients with spinal cord injuries (five out of six) developed a PU compared to those with lower extremity fractures (three out of 31). None of the aseline patient variales was significantly different etween patients who did and did not develop a PU (see Tale 1). Risk factors. Of all patient and skin variales assessed, only the variales sensory perception and moisture were significantly different etween persons who did and did not develop a PU (P <0.05) (see Tale 2). Similarly, crude logistics analysis showed that reduced sensory perception and constant moisture on admission were significant predictors of PU occurrence (see Tale 3). Patients with impaired sensory perception were 45 times more likely to develop a PU (95% CI: , P = ) and patients with constant moisture were more than 10 times more likely to develop an ulcer (OR = 10.7, 95% CI: , P = 0.008) as persons not experiencing these issues. On multivariate analysis using the hierarchical method of selection, sensory perception and moisture remained predictive of PU development. Adjusted OR showed that, while controlling for moisture, persons with impaired sensory perception at aseline were 43 times (95% CI: ) more likely to have a PU. Likewise, adjusting for sensory perception, the adjusted OR for constant moisture was 10 (95% CI: ). Among the eight patients who developed PUs, six had impaired sensory perception, six had constant moisture, and five had oth impaired sensory perception and constant moisture. The likelihood ratio test showed oth factors were predictive of developing a PU (P = ). Discussion Incidence variaility among studies. In this prospective study involving patients admitted to an orthopedic ward, the total cumulative PU incidence was 20% (eight out of 40) with a median time of 7 days from time of admission to study outcome. This incidence was relatively high compared to previous studies y Perneger et al 24 (14.2%) and Allman et al 1 (12.5%) with median occurrence of 9 days, and Chan et al 21 (9.1%) and Reed et al OSTOMY WOUND MANAGEMENT OCTOBER

4 PRESSURE ULCERS IN ORTHOPEDIC PATIENTS Tale 2. Baseline patient assessment variales y pressure ulcer outcome Nonlanchale erythema Dry skin No pressure ulcer (n = 32) Pressure ulcer (n=8) P value a No Yes 2 2 No Yes 9 1 Impaired sensory perception No Yes 2 6 Constant moisture No Yes 7 6 Limited activity No 0 0 Yes 32 8 Limited moility Poor nutrition Friction-Shear No Yes 27 7 No 23 5 Yes No 0 0 Yes 32 8 (14.7%). However, the incidence in this study was lower compared to Verschueren et al 26 (36.5%). The differences in the incidence rate may e due to the variaility in the age of the study population; the average age of current study participants was lower than that of other studies. 1,26 Determining risk factors. Although few studies have investigated risk factors for orthopedic patients, reduced sensory perception, small ody uild for height, and the presence of moisture were found to e predictors for PU development in a prospective cohort study involving 197 orthopedic patients. 21 The current study results confirm the role of sensory perception and the presence of moisture in PU occurrence. Risk assessment in PU prevention has een studied to help create a targeted approach to PU management and prevention. 19 Several factors known to e associated with the occurrence of PU have een investigated. This study suggests that sensory perception and moisture were predictive of the development of Stage II or greater PUs; factors reported in other studies 2,24-26 to e predictive of PU occurrence were not shown to e significant predictors of PU in this study. Nonlanching erythema, 1,28 dry skin, 1,8 frictionshear, 22 nutrition, 22,29,30 moility, 31 and the Braden Risk Assessment Scale scores 6,7,20,21 were not shown to e predictive of PU in this suset of orthopedic patients after multivariate regression analysis. More patients with spinal cord injuries (five out At risk c No Yes 15 6 a Fisher s Exact test significant at P 0.05; excluded ecause of collnearity; c at risk = Braden Risk Scale score variales dichotomized to at risk (low, medium, high risk) and not at risk 7 OCTOBER 2011 OSTOMY WOUND MANAGEMENT 67

5 FEATURE Tale 3. Crude analysis of risk factors for pressure ulcer a Risk factor Odds ratio 95% CI P value a Nonlanchale erythema Dry skin Sensory perception Moisture Activity - - Moility Nutrition Friction-shear - - At risk a Univariate logistic regression, P value significant at 0.10 Not done ecause of colinearity of six) developed a PU compared to those with lower extremity fractures (three out of 31). In persons with spinal cord injuries, multivariate analysis showed oth impaired sensory perception and moisture were predictive of PU formation. 28,30 Challenges to accurate assessment. The large confidence intervals for the OR for factors studied may show some imprecision. Assessing the presence of nonlanchale erythema may e challenging in persons with fair or dark-colored skin, such as the Filipinos. In this study, only four patients presented with nonlanching erythema on admission and two of them eventually developed Stage II ulcers. Also, age and associated age-related changes and concomitant comoridities make the older population prone to PUs. 8,22 In addition, the evidence regarding the role of alumin in predicting PU formation remains inconclusive. In recent studies, lymphopenia as well as low serum alumin 2,32 were shown to e predictors of PU formation in an elderly population. To the contrary, Gallagher et al 31 did not find the alumin status of adult patients to e a predictor of PU formation after multivariate analysis. Yet in the current study, 70% of patients had low alumin levels on admission. This could explain why the variale was not significantly different. Some authors 32 suggest that the association etween hypoaluminemia and PUs in past studies may e explained y protein losses in persons with PUs; this is especially true in cross-sectional studies and case-control or retrospective studies. 2 The degree of moility as part of the Braden scale has een consistently reported to e a predictor of PU. 21,31,33 On univariale analysis in this study, only impaired sensory perception and moisture were significant, with P = and OR = 10.7 (95% CI: 1.75, 65.2). Also, using a score of 18 as the cut-off for at risk per the Braden Risk Assessment Scale was not a predictor of PU in this study, contrary to other research, 6,7,20-22 again potentially related to the sample. On multivariate logistic regression analysis, oth impaired sensory perception (OR 43) and the presence of moisture (OR 10) were shown to e predictors of PU formation. Among the 40 patients in this study, six out of eight patients who developed PUs had impaired sensory perception. Likewise, among those who also developed PUs, six out of eight also had constant moisture and five of these patients also had impaired sensory perception. Based on the results of this and other studies, protocols for patient care must address skin moisture, especially in persons such as spinal cord injury patients with impaired sensory perception. Although constant moisture was a factor in a study of patients in an intensive care unit, 34 studies on moisture as an individual risk factor in spinal cord injury patients are not common. Moisture may have een incorporated in the Braden Risk Assessment Scale 20,22,27 or may e related to incontinence ecause oth urinary and fecal incontinence may cause constant soiling and moisture of the skin, especially in the sacral area. 1,33,34 Limitations One of the main limitations of this study was that patient comoridities were not included as study variales. Although other researchers 7,11,29 consider comoridities such as age, infection, diaetes, chronic diseases, and malignancy predictors of PUs, the current study was not ale to include them as possile risk factors. Matching groups in the data collection stage or performing a sugroup analysis could have facilitated inclusion of comoridities. Another limitation was the small sample size. The large CI for the estimated OR underscored the lack of adequate sample size, even though most of the patients who developed an ulcer had a history of spinal cord injury. This should e addressed in future studies. Conclusion The purpose of this prospective study was to determine if nonlanchale erythema, dry skin, Braden Risk Assessment Scale parameters, and risk assessment per the Braden scale were risk factors for PU formation among patients admitted to an orthopedic ward. The incidence of PUs was 20% and impaired sensory perception and constant moisture were predictive of PU formation. Identifying these 68 OSTOMY WOUND MANAGEMENT OCTOBER

6 PRESSURE ULCERS IN ORTHOPEDIC PATIENTS factors should help facilities institute preventive measures to avoid PU occurrence and susequent expensive care. This may translate into improvement of the quality of care and possile reduction in costs. n References 1. Allman, RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA. 1995;273(11): Allman RM, Laprade CA, Noel LB, Walker JM, Moorer CA, Dear MR, Smith CR. Pressure sores among hospitalized patients. Ann Intern Med. 1986;105(3): Andersen KE, Jensen O, Kvorning SA, Bach E. Prevention of pressure sores y identifying patients at risk. Br Med J. 1982;284(6326): Murray LD, Magazinovic N, Stacey MC. Clinical practice guidelines for the prediction and prevention of pressure ulcers. Primary Intention. 2001;9(3): Kim TN, Lang N. Predictive modeling for the prevention of hospitalacquired pressure ulcers. Proceedings from the American Medical Informatics Association (AMIA) Symposium. 2006: Bours GJ, Halfens RJ, Au-Saad HH, Grol RT. Prevalence, prevention, and treatment of pressure ulcers: descriptive study in 89 institutions in the Netherlands. Res Nurs Health. 2002;25: Bergstrom N, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. 1992;40(8): Guralnik JM, Harris TB, White LR, Cornoni-Huntley JC. Occurrence and predictors of pressure sores in the National Health and Nutrition Examination survey follow-up. J Am Geriatr Soc. 1988;36(9): Patterson RP, Cranmer HH, Fisher SV, Engel RR. The impaired response of spinal cord injured individuals to repeated surface pressure loads. Arch Phys Med Rehail. 1993;74: Makhsous M, Priee M, Bankard J, Rowles D, Ziegler M, Chen D, Lin F. Measuring tissue perfusion during pressure relief maneuvers: insights into preventing pressure ulcers. J Spinal Cord Med. 2007;30: Margolis DJ, Knauss J, Bilker W, Baumgarten M. Medical conditions as risk factors for pressure ulcers in an outpatient setting. Age Ageing. 2003;32: Goode HF, Burns E, Walker B. Vitamin C depletion and pressure sores in elderly patient with femoral neck fractures. BMJ. 1992;305: Smith BM, Guihan M, LaVela SL, Garer SL. Factors predicting pressure ulcers in veterans with spinal cord injuries. Am J Phys Med Rehail. 2008;87: Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006; 296: Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized medicare patients at risk for pressure ulcers. Arch Intern Med. 2001;161: De Laat EH, Schoonhoven L, Pickkers P, Vereek AL, Van Achtererg T. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care. 2006;18(2): Makai P, Koopmanschap M, Bal R, Nieoer AP. Cost-effectiveness of a pressure ulcer quality collaorative. Cost Eff Resource Alloc. 2010;Jun 1;8: Vu T, Harris A, Duncan G, Sussman G. Cost-effectiveness of multidisciplinary wound care nursing homes: a pseudo-randomized pragmatic cluster trial. Fam Pract. 2007;24: Strating M, Zuiderent-Jerak T, Neioer A, Bal R. Evaluating the Care for Better Collaorative Results of the First Year of Evaluation. Rotterdam: Institute of Health Policy and Management; Brown SJ. The Braden Scale. A review of the research evidence. Orthop Nurs. 2004;23(1): Chan WS, Pang SM, Kwong EW. Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting. J Clin Nurs. 2009;18(11): De Souza DM, Santos VL, Iri HK, Sadasue Oguri MY. Predictive validity of the Braden Scale for pressure ulcer risk in elderly residents of long-term care facilities. Geriatr Nurs. 2010;31(2): Pressure Ulcer Prevention Guidelines updated July 1, Availale at Accessed Novemer 3, Perneger TV, Raë AC, Gaspoz JM, Borst F, Vitek O, Héliot C. Screening for pressure ulcer risk in an acute care hospital: development of a rief edside scale. J Clin Epidemiol. 2002;55(5): Reed RL, Hepurn K, Adelson R, Center B, McKnight P. Low serum alumin levels, confusion, and fecal incontinence: are these risk factors for pressure ulcers in moility-impaired hospitalized adults? Gerontology. 2003;49(4): Verschueren JH, Post MW, de Groot S, van der Woude LH, van Aseck FW, Rol M. Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehailitation. Spinal Cord. 2011;49(1): Young J, Nikoletti S, McCaul K, Twigg D, Morey P. Risk factors associated with pressure ulcer development at a major western Australian teaching hospital from 1998 to 2000: secondary data analysis. J WOCN. 2002;29(5): Vanderwee K, Grypdonck M, Defloor T. Non-lanchale erythema as an indicator for the need for pressure ulcer prevention: a randomizedcontrolled trial. J Clin Nurs. 2007;16(2): Uzun O, Tan M. A prospective, descriptive pressure ulcer risk factor and prevalence study at a university hospital in Turkey. Ostomy Wound Manage. 2007;53(2): Chauhan VS, Goel S, Kumar P, Srivastava S, Shukla VK. The prevalence of pressure ulcers in hospitalized patients in a university hospital in India. J Wound Care. 2005;14(1): Gallagher P, Barry P, Hartigan I, McCluskey P, O Connor K, O Connor M. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viail. 2008;17(4): Anthony D, Rafter L, Reynolds T, Aljezawi M. An evaluation of serum alumin and the su-scores of the Waterlow score in pressure ulcer risk assessment. J Tissue Viail. 2011;20(3): Sharp CA, McLaws ML. Estimating the risk of pressure ulcer development: is it truly evidence ased? Int Wound J. 2006; 3(4): Suriadi, Sanada H, Sugama J, Kitagawa A, Thigpen B, KInosita S, et al. Risk factors in the development of pressure ulcers in an intensive care unit in Pontianak, Indonesia. Int Wound J. 2007;4(3): OCTOBER 2011 OSTOMY WOUND MANAGEMENT 69