An Australian experience of managing pressure ulcers in persons with SCI

Pressure ulcers are a difficult and complex problem, frequently resulting in poor patient outcomes ,and significantly increased cost of care. This project evolved from a desire to improve the management and subsequent outcomes for persons with spinal cord injury (SCI) who experience pressure ulcers acquired in the community. The vast body of work related to pressure ulcers has focused on risk assessment and prevention. However, there has been little interest in the management of prevailing pressure ulcers. Using a retrospective case history audit and interviews with patients and health care workers from an Australian spinal services unit, current practices associated with the care of pressure ulcers are described. A number of issues are identified that relate to funding, diet, attitudes, consistency of care, and low levels of staff interest in pressure ulcer management. This work provides baseline data from which current management practices can be reviewed, revised, and empirically evaluated.

Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: A randomised controlled trial

Background & Aims
Nutrients putatively implicated in pressure ulcer healing were evaluated in a clinical setting.

Methods
Sixteen inpatients with a stage 2, 3 or 4 pressure ulcer randomised to receive daily a standard hospital diet; a standard diet plus two high-protein/energy supplements; or a standard diet plus two high-protein/energy supplements containing additional arginine (9 g), vitamin C (500 mg) and zinc (30 mg). Nutritional status measurements (dietary, anthropometric and biochemical) and pressure ulcer size and severity (by PUSH tool; Pressure Ulcer Scale for Healing; 0=completely healed, 17=greatest severity) were measured weekly for 3 weeks.

Results
Patients’ age and BMI ranges were 37–92 years and 16.4–28.1 kg/m2, respectively. Baseline PUSH scores were similar between groups (8.7±0.5). Only patients receiving additional arginine, vitamin C and zinc demonstrated a clinically significant improvement in pressure ulcer healing (9.4±1.2 vs. 2.6±0.6; baseline and week 3, respectively; P<0.01). All patient groups presented with low serum albumin and zinc and elevated C-reactive protein. There were no significant changes in biochemical markers, oral dietary intake or weight in any group.

Conclusions
In this small set of patients, supplementary arginine, vitamin C and zinc significantly improved the rate of pressure ulcer healing. The results need to be confirmed in a larger study.

Nutrition therapy in the prevention and treatment of pressure ulcers

Pressure ulcers are serious problems within hospital and aged care settings and are associated with adverse health outcomes and high treatment costs. Because of a high incidence of pressure ulcers in the health system, attention is now being directed to not just preventing, but also more effectively treating them. Nutrition plays a fundamental part in wound healing, with malnutrition, dehydration and recent weight loss identified as independent risk factors for the development of pressure ulcers. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and vitamins A, C and E have been documented. There is reasonable evidence to show that nutritional support, mostly by high-protein oral nutritional supplements, is effective in significantly reducing the incidence of pressure ulcers in at-risk patients by 25%. Intervention studies using high-protein or specialised disease-specific nutritional supplements support a trend to increased healing of established pressure ulcers. Such specialised supplements are typically based on defined amounts of arginine, vitamin C and zinc. Mechanisms by which nutritional support can aid in pressure ulcer prevention and healing are likely related to addressing macro- and/or micro-nutrient deficiencies arising from either poor oral intake or increased nutrient requirements related to the wound healing process. With much more research still to be done in this area, nutrition support appears an efficacious and costeffective adjunct to current medical and nursing approaches in the prevention and treatment of pressure ulcers.

Use of an arginine-enriched oral nutrition supplement in the healing of pressure ulcers in patients with spinal cord injuries : an observational study

Aim: Pressure ulcers are a serious secondary consequence of spinal cord injuries. The objective of the present study was to determine whether an arginine-containing nutritional supplement can reduce the healing time of pressure ulcers in people with spinal cord injuries compared with those not consuming the supplement until full wound healing.

Methods: Thirty-four spinal cord injured patients with a grade 2, 3 or 4 pressure ulcer were prescribed two 237 mL tetrapaks/day of a supplement containing additional protein, arginine, zinc and vitamin C. Pressure ulcer healing was assessed with the Pressure Ulcer Scale for Healing tool.

Results: Twenty patients consumed the nutritional supplement until full pressure ulcer healing had occurred, while 14 patients ceased consuming the supplement before full healing occurred because of intolerance, compliance or taste issues. A 2.5-fold greater rate of healing was observed in patients consuming the supplement until full healing compared with those who ceased taking the supplement (8.5 ± 1.1 weeks vs 20.9 ± 7.0 weeks respectively; P = 0.04). There were no significant differences in age, nutritional status, gender or reason for admission between groups. Comparison of healing rates in the group consuming the supplement to full wound healing against expected rates derived from the medical literature showed a significantly shorter time-to-healing (grade 3 pressure ulcer: 6.5 ± 0.8 weeks vs 18.2 weeks; grade 4: 11.4 ± 2.0 weeks vs 22.1 weeks; P < 0.001).

Conclusion: The present small-scale study demonstrated the potential for specialised wound healing nutritional supplements to shorten the time to pressure ulcer healing in spinal cord injured patients.

The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers

Objective: To investigate if a lower dose of arginine in the form of an oral nutritional supplement can show similar benefit in the healing rate of pressure ulcers compared with the current evidence for 9g of arginine.

Method: Twenty-three inpatients with category II, III or IV pressure ulcers were randomised to receive daily, for 3 weeks, the standard hospital diet plus 4.5 or 9g arginine in the form of a commercial supplement. Pressure ulcer size and severity was measured weekly (by PUSH tool; pressure ulcer scale for healing; 0= completely healed, 17= greatest severity). Nutritional status was determined by Subjective Global Assessment.

Results: There were no significant differences in patients’ age, gender, BMI, haemoglobin levels, albumin levels and diagnosis of diabetes between treatment groups. There was a significant decrease in pressure ulcer severity over time (p < 0.001), with no evidence of a difference in healing rate between the two arginine dosages (p=0.991). Based on expected healing time, patients in both treatment groups were estimated to achieve an almost 2-fold improvement compared with the historical control group. Patients categorised as malnourished showed clinically significant impaired healing rates compared with wellnourished patients (p=0.057), although this was unaffected by arginine dosage (p=0.727).

Conclusion: Similar clinical benefits in healing of pressure ulcers can be achieved with a lower dosage of arginine, which can translate into improved concordance and significant cost-savings for both the health-care facilities and for patients.

The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial.

Little is known about the cost-benefit of soft silicone foam dressings in pressure ulcer (PU) prevention among critically ill patients in the emergency department (ED) and intensive care unit (ICU). A randomised controlled trial to assess the efficacy of soft silicone foam dressings in preventing sacral and heel PUs was undertaken among 440 critically ill patients in an acute care hospital. Participants were randomly allocated either to an intervention group with prophylactic dressings applied to the sacrum and heels in the ED and changed every 3 days in the ICU or to a control group with standard PU prevention care provided during their ED and ICU stay. The results showed a significant reduction of PU incidence rates in the intervention group (P = 0·001). The intervention cost was estimated to be AU$36·61 per person based on an intention-to-treat analysis, but this was offset by lower downstream costs associated with PU treatment (AU$1103·52). Therefore, the average net cost of the intervention was lower than that of the control (AU$70·82 versus AU$144·56). We conclude that the use of soft silicone multilayered foam dressings to prevent sacral and heel PUs among critically ill patients results in cost savings in the acute care hospital.

A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex^® Border Sacrum and Mepilex^® Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi-layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.

The PREPARE pilot RCT of home-based progressive resistance exercises for venous leg ulcers

OBJECTIVE: To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers. METHOD: Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratified by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device. RESULTS: Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing). CONCLUSION: A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.

Nursing documentation of pressure ulcers in nursing homes: comparison of record content and patient examinations

AIM: The aim of this study was to describe the accuracy and quality of nursing documentation of the prevalence, risk factors and prevention of pressure ulcers, and compare retrospective audits of nursing documentation with patient examinations conducted in nursing homes.

DESIGN: This study used a cross-sectional descriptive design.

METHOD: A retrospective audit of 155 patients' records and patient examinations using the European Pressure Ulcer Advisory Panel form and the Braden scale, conducted in January and February 2013.

RESULTS: The prevalence of pressure ulcers was 38 (26%) in the audit of the patient records and 33 (22%) in patient examinations. A total of 17 (45%) of the documented pressure ulcers were not graded. When comparing the patient examinations with the patient record contents, the patient records lacked information about pressure ulcers and preventive interventions.

Influences of spatial practices on pressure ulcer management in the context of spinal cord injury

Nursing practice is significantly influenced by the type and use of space in which nursing is practised. While investigating current patterns of service delivery for the management of pressure ulcers from the perspective of people with spinal cord injuries and their families, the space in which care was delivered was identified as a central determinant of care. Qualitative methods were used to investigate consumer perspectives among patients residing in both metropolitan and rural communities who had been hospitalized for the management of pressure ulcers. Issues related to the spatial practices of the hospital are discussed, demonstrating a link between well-being and the creation of an appropriate caring milieu. It is concluded that service could be improved markedly if health-care professionals placed more consideration on the impact of space on their service delivery.

Apoptosis may underlie the pathology of zinc-deficient skin

The trace element zinc is essential for the survival and function of all cells. Zinc deficiency, whether nutritional or genetic, is fatal if left untreated. The effects of zinc deficiency are particularly obvious in the skin, seen as an erythematous rash, scaly plaques, and ulcers. Electron microscopy reveals degenerative changes within keratinocytes. Despite the well-documented association between zinc deficiency and skin pathology, it is not clear which cellular processes are most sensitive to zinc deficiency and could account for the typical pathological features. We used the cultured HaCaT keratinocyte line to obtain insight into the cellular effects of zinc deficiency, as these cells show many characteristics of normal skin keratinocytes. Zinc deficiency was induced by growing cells in the presence of the zinc chelator, TPEN, or by growth in zinc-deficient medium. Growth of cells in zinc-deficient medium resulted in a 44% reduction of intracellular zinc levels and a 75% reduction in the activity of the zinc-dependent enzyme, 5'-nucleotidase, relative to the control cells. Over a period of 7 days of exposure to zinc-deficient conditions, no changes in cell viability and growth, or in the cytoskeletal and cell adhesion systems, were found in HaCaT cells. At 7 days, however, induction of apoptosis was indicated by the presence of DNA fragmentation and expression of active caspase-3 in cells. These results demonstrate that apoptosis is the earliest detectable cellular change induced by zinc deficiency in HaCaT keratinocytes. Our observations account for many of the features of zinc deficiency, including the presence of degenerate nuclei, chromatin aggregates and abnormal organization of keratin, that may represent the later stages of apoptosis. In summary, a major causal role for apoptosis in the pathology of zinc deficiency in the skin is proposed. This role is consistent with the previously unexplained diverse range of degenerative cellular changes seen at the ultrastructural level in zinc-deficient keratinocytes.

Frailty, aging, and incontinence in the elderly : an interactive case-based discussion of best practices

Urinary incontinence and frailty are both highly prevalent in older adults. Workshop goals include review of available evidence on frailty and differentiation from normal physiological aging. The influence of frailty on continence in older adults will be examined. Presentations will explore associated risks such as falls, pressure ulcers, and nursing home placement, as well as barriers and facilitators of continence care in various living environments. The role of urodynamics and various treatments will be considered. A majority of the session will focus on interactive discussion of case-based examples of common but challenging clinical situations seen in frail older adults.

Developing a dialysis centre foot screening culture

Foot lesions are common in the dialysis population and contribute to increased morbidity and mortality (Broersma 2004). lmportantly, patients on dialysis with and without diabetes are at increased risk of foot ulcers (Jones et al. 2012) and lower limb amputation (Kaminski, Frescos & Tucker 2012). Simple foot screening in dialysis centres can identify those at risk of foot complications and the presence of foot ulcers (Ahmad 2009; Ng et al. 2003). Valid and reliable foot screening tools have been developed in the dialysis context to identify those at risk and those with actual ulcers (Murphy et al. 2012).ln 2011, following the completion of a Diabetes and Renal Pilot Study and staff education, Moorabbin Haemodialysis Unit and Southern Health, identified the need to formalise foot screening for all patients and increase the rate at which these were conducted. The aim of this report is to present a summary of the audit evaluation of foot health screens and referrals in our dialysis centre.

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9-year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual-care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital-acquired pressure ulcers decreased following implementation of an evidence-based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual-care nurses under-estimated patients' risk of pressure ulcer development and under-utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital-acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.

Public sector residential aged care: identifying novel associations between quality indicators and other demographic and health-related factors

Objective : To explore associations among quality indicators (QI; e.g. pressure ulcers, falls and/or fractures, physical restraint, use of multiple medications, unplanned weight loss) of the Victorian Public Sector Residential Aged Care Services (VPSRACS) with other demographic and health-related factors.

Methods : Data for 380 residents over a 3-month period were extracted retrospectively from client databases at four VPSRAC facilities.

Results : Four significant logistic regression models were developed. The strongest models related to falls and polypharmacy. Significant associations for these models included the following: (1) residents with a higher body mass index were 6% less likely (95% confidence interval (CI) 1%–11%) to fall, whereas high levels of cognitive impairment increased the risk of falling by 8% (95% CI 2%–14%); (2) being ambulant with a gait aid more than doubled the risk of falling compared with non-ambulant residents (95% CI 19%–546%); and (3) higher cognitive impairment was associated with a 6% (95% CI 1%–11%) reduction in the likelihood of polypharmacy.

Conclusions : Identification of significant relationships between the VPSRACS QI and other demographic and health-related factors is a preliminary step towards a more in-depth understanding of the factors that influence the QI and predict adverse events.