Quality of Care and Pressure Ulcer Prevention: Not a Just a Matter of Risk and Intervention

If preventing pressure ulcers (PUs) is an important component of your job, teaching responsibilities, or studies, this issue of OWM is for you. Four (4) original research articles shed light on current acute care practice issues, the science of risk prediction, and the fact that implementing all known evidence-based prevention efforts may not be enough to stop the development of these ulcers or deep tissue injury (DTI). Research conducted by Amir et al¹ utilized a modified Donabedian model to examine the quality of PU care variables in 4 acute care hospitals in Indonesia. This model is useful for evaluating health care quality in research and practice and helped shape the development of nursing quality indicators.² Utilizing this model, Amir et al¹ identified several outdated PU prevention measures as well as 1 structural, 1 process, and 7 patient-related variables that affected the rate of facility-acquired PUs.  

Razmus et al³ used data from the National Database of Nursing Quality Indicators® to conduct a long overdue and much-needed study to examine PU prevention practices among pediatric patients. Among the findings, it was noted PU risk was assessed in most patients (33 644, 89.2%), approximately 30% of them were at risk, risk assessment methods varied, and pressure-redistribution surfaces were used in only 70% of at-risk patients. The authors concluded more research is needed to optimize PU prevention in pediatric patients. If you are involved in the care of this population, consider these study findings and how you can to apply them. 

The need for more research (specifically, studies to refine PU risk scales for acute care patients) also was identified by Chen et al.⁴ They used statistical methods and data from the records of 2588 patients to examine risk factors for PU development in general and the construct validity of the Braden Scale in particular. The authors found the original Braden Scale had inadequate construct validity in this acute care population, but 3 of the Braden subscales (sensory perception, mobility, and moisture) were independent predictors of ulcer development. 

Kirkland-Kyhn et al⁵ similarly observed total Braden Scale risk score was not an independent risk factor for the development of DTI among intensive care unit (ICU) patients. Using 5 years of data, they found all ICU patients were assessed as being at-risk (as evidenced by a low Braden score). Yet despite provision of appropriate interventions, DTIs still occurred. Specifically, patients with documented episodes of poor perfusion (low blood pressure), prolonged surgical procedures, or a history of hemodialysis or shock had a significantly higher risk of developing DTIs that became a Stage 3, Stage 4, or unstageable ulcer than patients who did not have these risk factors. The authors hypothesized that, because all patients received appropriate, risk-based prevention interventions, the Braden Scale was no longer useful for predicting risk in these ICU patients. Rather, perfusion-related risk factors should be considered. Based on these and other observations from the literature, the authors also stated that when modifiable risk factors are addressed, patient-related risk factors (not quality of nursing care) drive hospital-acquired PU rates. This brings us back to the observations by Amir et al¹: many more patient variables than care, structure, or process variables were statistically significantly associated with PU outcomes. 

Although there is considerable evidence and little doubt PU prevention is multifaceted and basic standards of care must be met, it is also increasingly clear that: 1) our understanding of patient-specific risk factors and how to address them, especially in acute and intensive care environments, remains limited, and 2) PUs will occur despite optimal nursing care because some risk factors may not be amenable to intervention. Hence, the development of an ulcer in these subsets of patients may be unavoidable. 

Thanks to dedicated researchers and increased access to and availability of “big data,” our understanding of PU etiology, risk factors, and optimal approaches to care is increasing rapidly. The substantial contributions to our collective knowledge brought to you by the 4 teams of dedicated researchers featured in this issue of OWM are noteworthy and practical. Put them to good use! 

This article was not subject to the Ostomy Wound Management peer-review process.