Pressure Ulcers in a University Hospital: A Review of Nursing Records

Introduction. The use of indicators in health care is a way to improve the quality of health services through the review of records. The aim of this study was to review nursing documentation related to pressure ulcers (PUs) contained in medical records of patients from a university hospital to assess the quality of nursing records regarding pressure ulcer development. Methods. The sample consisted of medical records of patients at risk for PUs who later developed the condition. Of the 684 records of patients ‘at risk,’ 118 reported on patients who developed PUs, and of these, 97 were selected for the study. Statistical analysis was performed using McNemar’s test and Wilcoxon test. Results. The mean age of the patients was 69.5 ± 16 years (range 18-100 years), and the mean length of hospital stay was 36.2 days (range 1-100 days). Intensive care unit patients comprised 57 (59%) of the PU cases, and those on inpatient units 30 (31%). Most PUs were found in the sacral region (88%); 30 (31%) of the PUs were stage II; and 22 (23%) were Stage I. Preventive measures included patient repositioning (n = 74) and use of moisturizers (n = 69). Conclusion. Despite shortcomings in the nursing documentation related to PUs, the information was gradually recorded and updated by the health professionals during the course of the patient’s hospital stay.

  Health professionals continuously pursue excellence in patient care, stimulating the discussion on the quality and assessment of health care among managers, assistants, and users.¹ The use of health care quality indicators allows the identification of opportunities for improvement in the quality of care by making it possible to detect differences between the care actually provided and expected standards. Quality indicators can also be used to identify and direct attention to key issues in health care that need to be reviewed.²   Nursing audits can be used to determine the efficacy of methods of nursing practice to ensure the quality of the care provided. The analysis of patient records and detailed review of nursing documentation allow the planning, execution, and management of nursing care; qualitative outcome assessment; and systematic assessment of the quality of care.³ Nursing records must be objective and standardized, because they are not only a source of data for the audit, but also provide information about the nursing care given to the patient. The records can also be used as an instrument for the protection of these health professionals against legal liability.⁴   Despite all the resources available to ensure positive outcomes and satisfied clients, the number of problems caused by human error is still high in health care institutions. Therefore, patient safety is one of the critical components of health care quality and is considered by the World Health Organization as a global public health problem.⁵ Adverse events play an important role in patient safety and are defined as unwanted complications caused by health care management rather than by the underlying disease.⁶ An example of an adverse event is a pressure ulcer, which is a severe problem affecting hospitalized patients worldwide, with incidence varying from 0% to 14%.^7-10 Although pressure ulcers are caused by intrinsic and extrinsic factors, health professionals need to be involved in prevention efforts.^11,12   Much has been discussed about the causality, pathophysiology, and strategies for prevention and treatment of pressure ulcers, especially regarding risk groups such as patients with chronic or acute diseases and the elderly. Despite the fact that pressure ulcers have received a great deal of attention by the health care community, studies have revealed the incidence and prevalence of pressure ulcers are still high.^13-15 Brazilian and international studies have reported the incidence of pressure ulcers in university hospitals range from 3.2% to 66%.^16,17 There are no cost estimates of pressure ulcer treatment in Brazil, but international studies have reported that treatment costs range from $2,000 to $30,000 per patient, depending on the stage, and that the estimated annual cost can be as high as $1.3 billion.^14,16,18   Thus, prevention of pressure ulcers, regardless of the type of health care delivery system, requires a systematic approach that begins with the assessment of the patient at admission, takes into account the existing risks, adopts adequate preventive measures, and involves all members of the health care team to reduce pressure ulcer incidence.^14,16 In order to improve nursing interventions, nurse team leaders must have the knowledge and skills to assess, prescribe, and monitor interventions safely and effectively.¹⁹   The aim of this study was to review nursing documentation related to pressure ulcers contained in medical records of patients hospitalized at São Paulo Hospital (HSP), a university hospital in Brazil.

  This was a retrospective study based on records of patients hospitalized at HSP. The patient records are archived in the Medical and Statistical Archive Service.   São Paulo Hospital is a nonprofit, philanthropic institution affiliated to the Universidade Federal de São Paulo (UNIFESP) and is part of the Brazilian Unified Health System. São Paulo Hospital is classified as a level IV hospital, according to the Brazilian classification of hospitals, it provides treatment for the most complex and difficult cases. The HSP has 743 beds, of which 651 are for adults and 92 for children.   The nursing audit at HSP was started in 2006 in order to achieve the objectives set by the City and State of São Paulo Management Offices. Three objectives were set regarding nusing practice: 1) to perform a nursing audit in 5% of hospital discharge summaries and 30% of death certificates; 2) to evaluate the nurses’ compliance to the nursing care plan (NCP); and 3) to assess patient safety indicators, including the patient’s risk profile for pressure ulcers and number of pressure ulcers.   During 2009, 29,170 hospital discharges and 1,434 deaths were reported at HSP. A total of 2,385 patient reports were audited and 684 patients were considered at risk for pressure ulcers according to the Braden Scale, of which 118 developed pressure ulcers. The final sample consisted of 97 patient records; the records of 21 patients who developed pressure ulcers (as previously identified by an audit nurse) were missing at the time of the study, and therefore were excluded from the sample.   A data collection instrument was used to register information about patient identification, demographic information, nutritional status, Braden Scale scores, risk factors for pressure ulcers (eg, mechanical ventilation, sedation, hyperthermia, urinary incontinence, and fecal incontinence), pressure ulcer staging (according to the classification of the National Pressure Ulcer Advisory Panel [NPUAP]), and preventive measures (eg, use of convoluted foam mattress pad, heel protectors, cushions, timer with alarm attached to the bed to indicate the time for patient repositioning, skin barriers, and skin moisturizers). Individual patient data were analyzed at 4 time points chosen based on documentation of interventions and nursing progress notes. The 4 time points were: 1) date of admission, 2) date on which the patient was identified as being at risk for a pressure ulcer, 3) date of pressure ulcer diagnosis, and (4) date of discharge or death.   The Braden Scale for Predicting Pressure Sore Risk was used to assess patient risk. It contains 6 subscales rated from to 1 (low risk) to 4 (high risk), except for the friction and shear subscale, which is rated from 1 to 3. The sum of the 6 subscale ratings provides a total score ranging from 6 to 23. A cutoff score of 18 or less indicates increased risk for pressure-ulcer development. Based on the total score, risk groups are defined as follows: 6 to 9, very high risk; 10 to 12, high risk; 13 to 14, moderate risk; 15 to 18, at risk; and 19 to 23, not at risk.²⁰   Data collection was started after the study was approved by the Research Ethics Committee of the UNIFESP, Brazil, under the process number 500/10. Statistical analysis was performed using McNemar’s test and nonparametric Wilcoxon test.

  Of the 684 patients at risk for developing pressure ulcers (total Braden scores ≤ 18), 118 (17.25%) developed pressure ulcers, with a significant correlation between the presence of pressure ulcers and low total Braden scores (P = 0.035). Ninety seven nursing reports of patients with pressure ulcers were evaluated in the study. Fifty-seven (58.8%) patients were men and 40 (41.2%) women; the mean length of hospital stay was 36.2 days (range 1-100 days). The mean age of the patients was 69.5 ± 16 years (range 18-100 years) with the 71-80 years age being the largest (Table 1).   The primary diseases included infectious, metabolic, and autoimmune diseases (n = 55); respiratory diseases (n = 36); cardiovascular diseases (n = 36); cancers (n = 27); urological diseases (n = 24); neurological diseases (n = 23); orthopedic trauma (n = 8); and gastrointestinal diseases (n = 4).   The major risk factor for pressure ulcers at diagnosis was mechanical ventilation (n = 38) followed by hyperthermia (n = 22) and sedation (n = 20). There was a significant correlation between the number of patients under sedation and presence of pressure ulcers (P = 0.035)   Preventive measures included patient repositioning (n = 74), use of skin moisturizers (n = 69), convoluted foam mattress pad (n = 6), skin barriers (n = 4), and heel protector (n = 1).   Patients in intensive care units (ICU) comprised 57 (59%) of the pressure ulcer cases, those on inpatient units 30 (31%), and emergency room patients 10 (10%).   A total of 119 pressure ulcers were documented. Most pressure ulcers were found in the sacral region (n = 85); other body locations included the trochanteric region (n = 16), calcaneous (n = 15), ears (n = 2), and gluteal region (n = 1).   With regard to pressure ulcer staging, 30 ulcers were stage II, 22 were stage I, 11 were healing, 5 were unstageble pressure ulcers, 4 were stage III, 2 were stage IV, and the stage of 45 pressure ulcers was not indicated on the records.   It was found that 87 (89.7%) patients who development pressure ulcers were not assessed at admission for risk of pressure ulcers, 62 (63.9%) were assessed at prescription of preventive interventions, 48 (49.4%) at diagnosis of pressure ulcer, and 61 (62.8%) at hospital discharge or death. There was a significant correlation between the presence of pressure ulcers and at-risk Braden Scale scores at hospital discharge or death (P = 0.035).

  Quality of care and patient safety are important issues for health care providers, and technological innovations have lead to the development of new tools to help minimize errors in health care. However, errors can occur during interventions; therefore, adverse events are one of the most studied topics related to patient safety. Any type of error, mistake, incident, or diversion, whether or not resulting in harm to the patient, are examples of adverse events.^6,21 Prevention of adverse events associated with procedural errors is as important as their identification. A study reported that 10.8% of the patients from 2 British hospitals experienced an adverse event, that 1/3 of the events resulted in moderate harm or death, and that half of the events could be avoided by preventive measures.^6,21   Pressure ulcers are one of the most serious complications affecting critically ill hospitalized patients; they can result in prolonged hospital stay, slow recovery, and increased risk for other diseases. The NPUAP estimates more than 1 million hospitalized patients in the United States develop pressure ulcers annually.¹¹   According to the audit records, of the 684 patients at risk for developing pressure ulcers (total Braden scores ≤ 18), 118 (17.25%) developed pressure ulcers, with a significant correlation between the presence of pressure ulcers and low total Braden scores (P = 0.035). In a study on the quality of nursing documentation of pressure ulcers in an acute care setting in the Republic of Ireland, it was identified that 47% (n = 40) of patients were assessed as at high or very high risk of developing a pressure ulcer. Fifty-two patients (61%) had a weekly risk assessment, but 25% (n = 21) had only one follow-up assessment.²²   The current study included 97 patients who developed pressure ulcers; 57 (58.8%) of them were men and 40 (41.2%) were women. Although there are no studies in the literature associating gender with the presence of pressure ulcers, some studies have indicated men are more at risk for developing pressure ulcers than women.^17,18,23 Another study carried out at HSP also reported a higher prevalence of pressure ulcers among men (57.7%),^11,16 but this result may reflect the profile of the population seeking medical care at this hospital.   The mean age of patients with pressure ulcers was 69.5 years (range 18-100 years), and the predominant age group was 71 to 80 years, 28.8% of the study sample. The predominance of elderly patients with pressure ulcers (73.19%) found in this study is in agreement with the findings of other studies.^11,16 This was expected because advanced age is one of the most important risk factors for pressure ulcers. As the human body ages, a number of changes occur to the skin, such as thinning of the dermal layer, changes in vascularization, and decrease in epidermal proliferation, pain perception, inflammatory response, and barrier function, which leave the skin vulnerable to injuries.^11,16   The most frequent primary diseases were infectious, metabolic, and autoimmune diseases, followed by cardiovascular and respiratory diseases, which is in agreement with other studies in the literature.^16,23 Additionally, 27 patients had cancers and many of them were terminally ill. These patients presented with weight loss and decreased motor activity and sensorial perception, which are risk factors for pressure ulcer development.¹¹   Patients in the ICU and emergency unit accounted for 69.3% of the cohort. In another study, 62.5% of the ICU patients of a university hospital had pressure ulcers.¹⁷ This is in agreement with common knowledge that ICU patients are at a higher risk for developing pressure ulcers, because many are bedridden and have impaired sensorial perception caused by sedation, use of muscle relaxants, and analgesics. Most of these patients are severely ill and require complex treatments and care.^11,18   Pressure ulcers are mainly found in the sacral and trochanteric regions and at the calcaneus.^11,16,23 In the present study, pressure ulcers were found mostly in the sacral region (n = 85); other body locations included the trochanteric region (n = 16), calcaneus (n = 15), ears (n = 2), and gluteal region (n = 1). Regarding the staging of the pressure ulcers, 30 were stage II, 22 stage I, 11 were healing, 5 unstageble pressure ulcers, 4 were stage III, and 2 Stage IV. Because the definition of the stages of pressure ulcers has been frequently updated, it is difficult for nurses to keep up on the latest developments²⁴; this also makes it difficult to standardize patient records. However, these concepts have been increasingly incorporated into nursing training programs. Most of the pressure ulcers in this study were detected in the early stages, showing that nurses could efficiently identify the condition.   At the date of pressure ulcer diagnosis, the most significant risk factor was mechanical ventilation (n = 38), followed by sedation (n = 20). The goal of mechanical ventilation is to maintain adequate oxygen delivery to the tissues and carbon dioxide removal. However, ventilator support does not always provide tissue with adequate oxygenation; therefore, patients receiving mechanical ventilation are at risk for pressure ulcers. It is also important to highlight that repositioning is more difficult with a patient on mechanical ventilation.^25,26   Previous studies identified sedation as an extrinsic risk factor for pressure ulcer development, and revealed that sedated patients had almost a fivefold higher incidence of large and deep ulcers than nonsedated patients.^27,28 In the present study, there was a significant correlation between the presence of pressure ulcers and sedation.   Another important extrinsic risk factor for pressure ulcers is the exposure of the skin to moisture. According to the record audit, no patient had fecal incontinence and 46 patients did not require an indwelling bladder catheter. However, this information is not sufficient to estimate the influence of incontinence on pressure ulcer development in these patients. It is important to note that the audit was performed at selected time points, and therefore isolated episodes of fecal and urinary incontinence may not have been considered. Urinary and fecal incontinence are clinical conditions that may lead to a prolonged exposure of the skin to moisture, which may result in maceration. The use of skin barriers (eg, creams, transparent films, and zinc oxide cream) and urine collectors, and frequent changes of the absorbent pads or indwelling bladder catheter are measures that can be used to minimize the effects of moisture on the skin.^18,23   In this study, 22 cases of hyperthermia were identified; there was no case of hypothermia at pressure ulcer diagnosis, but 4 cases were identified at the date of death. Hyperthermia is considered an intrinsic risk factor for pressure ulcers,^23,29 as well as hypothermia, which causes vasoconstriction, reducing tissue oxigenation.30 However, hypothermia, as a risk factor for pressure ulcer development, is not well described in the literature.   Preventive measures included patient repositioning (n = 74), use of skin moisturizers (n = 69), convoluted foam mattress pad (n = 6), skin barriers (n = 4), and heel protector (n =1). The results indicated that some preventive measures were underreported, probably because these devices are intended for continuous use and do not require daily changes. The most frequently reported interventions were patient repositioning and use of skin moisturizers, which are easily performed by the nursing team; other interventions may require resources that are not always available to meet patient demand.¹⁶   A study on nursing documentation reported that only 45% (n = 38) of charts had some evidence of documented NCP, and of those, 53% (n = 20) had no evidence of implementation of the NCP and 66% (n = 25) had no evidence of outcome evaluation. Only 48% (n = 41) of this at-risk population was nutritionally assessed. Also, there was no record of regular positioning of patients admitted with and without a pressure ulcer in 70% (n = 59) and 60% (n = 51) of cases, respectively.²² In the current study, the data related to pressure ulcers were retrieved from nursing records documented in the NCP. The NCP is intended to improve the control of the quality of care and allows the nurse to better organize and manage activities. Despite the fact that this nursing process (including nursing documentation) has been used for about 30 years in Brazil, there are some implementation and maintenance issues which have yet to be resolved. It may be estimated that nursing documentation is responsible for more than 50% of the information found in the patient record. These data allow the evaluation and monitoring of the evolution of the patient’s condition, use of individual records for research purposes, evaluation of the quality of nursing care, and provide information for audit.^31,32   Although nursing audit has not been well-explored in Brazil, it has been gaining attention in health care settings because of its possible use as an instrument for the assessment of the quality of care in these institutions. Moreover, it allows a detailed review of selected clinical records and provides information for the planning, execution, and management of care and qualitative outcome analysis. It is impossible to have a health care service rated as good quality if the medical or nursing records do not exist or are incomplete.^3,32,33 A study in a Swedish university hospital found that the quality of the nursing documentation of pressure ulcers was generally poor and that patient records did not present valid and reliable data about pressure ulcers.³³ Guidelines are needed to support the care planning process and facilitate the use of research-based knowledge in clinical practice.^22,33,34 The proper use of electronic patient records may increase the quality of clinical data in the future.³³   In the present study, the Braden Scale was not administered to 87 (89.7%) patients at admission, probably because patients are usually assessed for risk of pressure ulcers between 24 and 48 hours after admission. A total of 258 pressure ulcer assessments were performed in the 97-patient study sample. It was found that 62 (63.9%) patients were assessed for risk of pressure ulcers at prescription of preventive interventions, 61 (62.8%) at diagnosis of pressure ulcers, and 48 (49.4%) at hospital discharge or death. Despite the fact that the Braden Scale was implemented in this institution in 2004 and that the nursing staff was trained in the use of the scale, the results showed the Braden Scale was not administered to all patients. However, it has been observed that the frequency of documentation of Braden Scale ratings in patient records has increased over the years in this institution. Other studies have also reported poor nursing documentation of pressure ulcers^22,33 and the need for standardized guidelines.³⁴   All interventions, despite its nature and type of health professional involved, should be documented in the patient records. The information provided has to be clear, objective, reliable, frequently updated, and complete to allow the monitoring, evaluation, and continuous planning of health care. The records are essential in patient care and, if accurately maintained, allow the assessment of the quality of health care.^21,35

  This was a preliminary study with the aim of reviewing nursing documentation related to pressure ulcers contained in patient records. Because this was a retrospective study some patient records were difficult to locate, and therefore were excluded from the sample, which is a limitation of the study. Other limitations were the use of selected time points for data collection as opposed to a broad analysis of the available information, and the impossibility of evaluating extensive patient records resulting from the prolonged hospital stay of some patients. Because of these limitations, many nursing notes were not evaluated.   Based on the data, the authors were unable to evaluate the possibility of some ulcers being considered “unpreventable,” so the topic was not discussed in this study. Further studies based on the detailed evaluation of all nursing documentation contained in the records of each patient are necessary.   The difficulty in maintaining detailed patient records is well known because an increase in the amount of time spent by nurses on documentation may reduce the amount of time on direct nursing care. Therefore, further studies are needed on the planning of nurse staffing based not only on the level of dependence of patients but also considering the amount of time necessary for indirect patient care activities. Quality improvement in nursing documentation related to pressure ulcer risk assessment and nursing interventions is one of the main goals of the nursing management team.   Although there were deficits in the patient records related to pressure ulcers, the information was gradually recorded and updated by the health professionals during the course of the patient’s hospital stay.

The authors are from the Division of Nursing, Hospital São Paulo, São Paulo, Brazil.

Address correspondence to: Maria Isabel Sampaio Carmagnani Hospital São Paulo CEP 04024-002 São Paulo, Brazil carmagnani@unifesp.br

Disclosure: The authors disclose no financial or other conflicts of interest.