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The aim of this study was to develop a tool to measure the knowledge of nurses on pressure ulcer prevention. PUKAT 2·0 is a revised and updated version of the Pressure Ulcer Knowledge Assessment Tool (PUKAT) developed in 2010 at Ghent University, Belgium. The updated version was developed using state-of-the-art techniques to establish evidence concerning validity and reliability. Face and content validity were determined through a Delphi procedure including both experts from the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) (n = 15). A subsequent psychometric evaluation of 342 nurses and nursing students evaluated the item difficulty, discriminating power and quality of the response alternatives. Furthermore, construct validity was established through a test-retest procedure and the known-groups technique. The content validity was good and the difficulty level moderate. The discernment was found to be excellent: all groups with a (theoretically expected) higher level of expertise had a significantly higher score than the groups with a (theoretically expected) lower level of expertise. The stability of the tool is sufficient (Intraclass Correlation Coefficient = 0·69). The PUKAT 2·0 demonstrated good psychometric properties and can be used and disseminated internationally to assess knowledge about pressure ulcer prevention., (© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

To compare the effectiveness of multi-stage and one-stage alternating low-pressure air mattresses (ALPAM) and alternating pressure air mattress (APAM) overlays in preventing pressure ulcers among hospitalized patients, data were pooled (N = 617) from a study of patients allocated to multi-stage ALPAM (n = 252) or one-stage ALPAM (n = 264), and another study of patients allocated to APAM overlay (n = 101). Cumulative pressure ulcer incidence was 4.9% (n = 30) over 14 days. Fewer ulcers developed on multi-stage ALPAM compared with APAM overlay (OR = 0.33; 95% CI [0.11, 0.97]), but no difference was found between one-stage ALPAM and APAM overlay (OR = 0.40; 95% CI [0.14, 1.10]). Time to develop ulcers did not differ by mattress type., (© 2013 Wiley Periodicals, Inc.)

Background: Frail older people admitted to nursing homes are at risk of a range of adverse outcomes, including pressure ulcers. Clinical decision support systems are believed to have the potential to improve care and to change the behaviour of healthcare professionals., Objectives: To determine whether a multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention improves adherence to recommendations for pressure ulcer prevention in nursing homes., Design: Two-armed randomized controlled trial in a nursing home setting in Belgium. The trial consisted of a 16-week implementation intervention between February and June 2010, including one baseline, four intermediate, and one post-testing measurement. Primary outcome was the adherence to guideline-based care recommendations (in terms of allocating adequate pressure ulcer prevention in residents at risk). Secondary outcomes were the change in resident outcomes (pressure ulcer prevalence) and intermediate outcomes (knowledge and attitudes of healthcare professionals)., Setting: Random sample of 11 wards (6 experimental; 5 control) in a convenience sample of 4 nursing homes in Belgium., Participants: In total, 464 nursing home residents and 118 healthcare professionals participated., Methods: The experimental arm was involved in a multi-faceted tailored implementation intervention of a clinical decision support system, including interactive education, reminders, monitoring, feedback and leadership. The control arm received a hard-copy of the pressure ulcer prevention protocol, supported by standardized 30 min group lecture., Results: Patients in the intervention arm were significantly more likely to receive fully adequate pressure ulcer prevention when seated in a chair (F=16.4, P=0.003). No significant improvement was observed on pressure ulcer prevalence and knowledge of the professionals. While baseline attitude scores were comparable between both groups [exp. 74.3% vs. contr. 74.5% (P=0.92)], the mean score after the intervention was 83.5% in the experimental group vs. 72.1% in the control group (F=15.12, P<0.001)., Conclusion: The intervention was only partially successful to improve the primary outcome. Attitudes improved significantly while the knowledge of the healthcare workers remained unsatisfactorily low. Further research should focus on the underlying reasons for these findings., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Aims: To gain insight into the knowledge and attitudes of nurses and nursing assistants and to study the correlation between knowledge, attitudes and the compliance with the pressure ulcer prevention guidelines provided to residents at risk of pressure ulcers in nursing homes., Background: There is a lack of evidence on knowledge and attitudes of nurses and nursing assistants towards pressure ulcer prevention in nursing homes., Design: A cross-sectional multi-centre study., Methods: A convenience sample of nine Belgian nursing homes, representing 18 wards was chosen in the study. In total, 145 nurses and nursing assistants were included. The compliance with the guidelines was evaluated in 615 residents, and data were collected using validated instruments., Results: Fully compliant prevention was found in only 6·9% of the residents at risk. The mean knowledge score of the nurses was 29·3 vs. 28·7% for the nursing assistants. The overall attitude score was 74·5%, and attitude scores were significantly different between nurses and nursing assistants. Nurses showed to have a more positive attitude towards pressure ulcer prevention than nursing assistants, respectively 78·3 and 72·3%. A more positive attitude was a significant predictor of pressure ulcer prevention compliance with the guidelines provided to residents at risk of pressure ulcers in nursing homes., Conclusions: Knowledge about pressure ulcer prevention of both nurses and nursing assistants in nursing homes was low. Attitudes were a significant predictor of the application of fully compliant prevention in residents at risk., Relevance to Clinical Practice: Pressure ulcer prevention is an important aspect in daily care for residents at risk in nursing homes. These insights will contribute to evidence-based practice in this area of care and will form the basis for the development of an education strategy for pressure ulcer prevention and management in nursing homes., (© 2011 Blackwell Publishing Ltd.)

Background: Evidence-based guidelines for pressure ulcer prevention have been developed and promoted by authoritative organizations. However, nonadherence to these guidelines is frequently reported. Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice., Aims: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of adequate prevention., Methods: A cross-sectional multicenter study was performed in a random sample of 14 Belgian hospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients). Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. From each participating ward, a random selection of at least five nurses completed an extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logistic regression analysis was performed to evaluate the correlation between knowledge, attitudes, and the application of adequate prevention., Results: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30% (625/2105) of the patients were at risk (Bradenscore <17 and/or presence of pressure ulcer). Only 13.9% (87/625) of these patients received fully adequate prevention whilst in bed and when seated. The mean knowledge and attitude scores were 49.7% and 71.3%, respectively. The application of adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). No independent correlation was found between knowledge and the application of adequate prevention (OR = 0.75, p = .71)., Conclusions: Knowledge of nurses in Belgian hospitals about the prevention of pressure ulcers is inadequate. The attitudes of nurses toward pressure ulcers are significantly correlated with the application of adequate prevention. No correlation was found between knowledge and the application of adequate prevention., (Copyright ©2011 Sigma Theta Tau International.)

Introduction: The development of a pressure ulcer is an adverse event and is often avoidable if adequate preventive measures are applied. No large-scale data, based on direct patient observations, are available regarding the pressure ulcer preventive interventions used in hospitals., Purpose: The aim of this study was to obtain insight into the adequacy of interventions used to prevent pressure ulcers in Belgian hospitals., Methods: A cross-sectional, multi-centre pressure ulcer prevalence study was performed in Belgian hospitals. The methodology used to measure pressure ulcer prevalence was developed by the European Pressure Ulcer Advisory Panel. The data collection instrument includes five categories of data: general data, patient data, risk assessment, skin observation and prevention., Results: The total sample consisted of 19,968 patients. The overall prevalence of pressure ulcers Category I-IV was 12.1%. Only 10.8% of the patients at risk received fully adequate prevention in bed and while sitting. More than 70% of the patients not at risk received some pressure ulcer prevention while lying or sitting., Conclusion: Generally, there is a limited use of adequate preventive interventions for pressure ulcers in hospitals, which reflects a rather low quality of preventive care. The implementation of pressure ulcer guidelines requires more attention. The pressure ulcer prevention used in practice should be re-evaluated on a regular basis.

Aims and Objectives: To investigate the effect of the implementation of a patient and family education programme for pressure ulcer prevention in an organisation for home care nursing on guideline adherence and on prevalence and severity of pressure ulcers and to examine the determining factors for the application of measures for pressure ulcer prevention., Background: Quality improvement programmes in pressure ulcer prevention are not always successful., Design: Implementation study using a pretest-post-test design. Data were collected in three probability samples. The first post-test data collection was held after six months, the second after 18 months., Method: Statistical analysis was used, comparing the pretest sample and the second post-test sample., Results: After 18 months, the proportion of subjects with adherent measures had increased from 10·4-13·9%, the proportion of subjects with non-adherent measures decreased from 45·7-36·0%, the proportion of subjects without pressure ulcer prevention increased from 43·9-50·1% (p<0·0001, Chi-square test). Sub-analysis revealed that a positive change in guideline adherence was observed principally in the group at risk. Better process-of-care indicators were associated by lower pressure ulcer prevalence and less severe skin lesions. The nurses' judgement of a patient risk status was the most important factor for applying preventive measures. Furthermore, application of pressure ulcer prevention was determined by higher age (from the age category of 70-79 years), higher dependency for the activities of daily living, higher than baseline mobility score and the presence of a pressure ulcer., Conclusions: Guideline adherence in pressure ulcer prevention changed significantly after implementation of the education programme. There might have been inconsistencies in the nurses' risk judgement., Relevance to Clinical Practice: Quality of pressure ulcer prevention improved, but several items for improvement remain. Adaptation of risk assessment procedures is needed., (© 2010 Blackwell Publishing Ltd.)

Aims and Objective: The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2-4) in nursing home patients with non-blanchable erythema., Background: No studies could be found that identify risk factors for further development of pressure ulcer in patients with non-blanchable erythema. For some patients with non-blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention., Design: Secondary data analyses of a previously conducted randomised controlled trial were performed., Methods: Eighty-four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non-blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system., Results: The cumulative pressure ulcer incidence was 18.7% (44/235). Hypotension (relative risk = 3.42, 95% CI = 1.56-7.49), a history of a cerebral vascular accident (relative risk = 1.94, 95% CI = 1.10-3.70) and contractures (relative risk = 2.02, 95% CI 1.03-3.95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%., Conclusions: In nursing home residents with non-blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions., Relevance to Clinical Practice: Patients with non-blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.

Aim: The aim of the study was to determine the effectiveness of two cushions in the prevention of heel pressure ulcers in a geriatric population., Background: Heel pressure ulcers are a major problem in nursing practice. Several measures for the prevention of heel pressure ulcers are discussed in the literature, but the effectiveness of the different types of cushions in the prevention of heel pressure ulcers is poorly studied., Methods: In this comparative study, two different cushions to prevent heel pressure ulcers were investigated: a wedge-shaped, bedwide, viscoelastic foam cushion and an ordinary pillow. All patients were lying on a viscoelastic foam mattress and were repositioned every 4 hours., Sample: One hundred sixty-two patients over 75 years of age., Results: The incidence of heel pressure ulcers grades 2-4 was 1.9% in the wedge-shaped cushion group and was 10.2% in the pillow group. The patients in the wedge-shaped cushion group developed significantly fewer heel pressure ulcers (p = 0.03). Patients with a wedge-shaped cushion under the lower legs had an 85% less chance in developing a heel pressure ulcer (p = 0.02). The median time to develop a heel pressure ulcer was 4.0 days (IQR = 3.0-5.0) in the wedge-shaped cushion group and 3.5 days (IQR = 1.0-5.8) in the pillow group (p = 0.61). The probability to remain pressure ulcer-free at the heels was significantly higher in the wedge-shaped cushion group (p = 0.008)., Conclusion: The study provides evidence that a wedge-shaped, bedwide, viscoelastic foam cushion decreases the risk of developing a heel pressure ulcer compared with the use of a pillow.

Aims and Objectives: The aim of this systematic literature review was to describe the current evidence in the field of pressure ulcer treatment with hydrocolloids and to give recommendations for clinical practice and further research., Background: Pressure ulcers are a common problem in clinical practice and generate substantial expense. A wide range of dressings is available but little is known about the effect on pressure ulcer healing., Methods: A Cochrane-based search strategy was used in four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to Nursing and Allied Health Literature), manuals and reference lists. Randomised controlled trials on the treatment of pressure ulcers with hydrocolloids, as defined by the British National Formulary, were systematically included and analysed., Results: Twenty-nine publications, dealing with 28 different studies, met the inclusion criteria and were included in the review. Hydrocolloids were most frequently used on pressure ulcers grade 2-3. Concerning the healing of the pressure ulcer, hydrocolloids are more effective than gauze dressings for the reduction of the wound dimensions. The absorption capacity, the time needed for dressing changes, the pain during dressing changes and the side-effects were significantly in favour of hydrocolloids if compared to gauze dressings. Based on the available cost-effectiveness data, hydrocolloids seemed to be less expensive compared with collagen-, saline- and povidine-soaked gauze but more expensive compared to hydrogel, polyurethane foam and collagenase., Conclusions: This review demonstrates that hydrocolloids are to be preferred to gauze dressings in the treatment of pressure ulcers. Additional research is needed to confirm these results., Relevance to Clinical Practice: Based on the studies included in this review, hydrocolloids are frequently used in the treatment of grade 2 and 3 pressure ulcers and are more effective and less expensive than gauze dressings. Compared with alginates, polyurethane dressings, less-contact layers, topical enzymes and biosynthetic dressings, hydrocolloids are less effective.

Objectives: The purpose of this paper is to examine and synthesise the literature on alternating pressure air mattresses (APAMs) as a preventive measure for pressure ulcers., Design: Literature review., Data Sources: PubMed, Cinahl, Central, Embase, and Medline databases were searched to identify original and relevant articles. Additional publications were retrieved from the references cited in the publications identified during the electronic database search., Results: Thirty-five studies were included. Effectiveness and comfort of APAMs were the main focuses of the studies evaluating APAMs. Pressure ulcer incidence, contact interface pressure, and blood perfusion were the most frequently used outcome measures to evaluate the effectiveness of APAMs. Fifteen randomised controlled trials (RCTs) analysed the pressure ulcer incidence. One RCT compared a standard hospital mattress with an APAM and found that the APAM was a more effective preventive measure. RCTs comparing APAMs with constant-low-air mattresses resulted in conflicting evidence. There was also no clear evidence as to which type of APAM performed better. All RCTs had methodological flaws. The use of contact interface pressure and blood perfusion measurements to evaluate the effectiveness of APAMs is questionable. Comfort of APAMs was the primary outcome measure in only four studies. Different methods for assessment were used and different types of APAMs were evaluated. Better measures for comfort are needed. A few studies discussed technical problems associated with APAMs. Educating nurses in the correct use of APAMs is advisable., Conclusion: Taking into account the methodological issues, we can conclude that APAMs are likely to be more effective than standard hospital mattresses. Contact interface pressure and blood perfusion give only a hypothetical conclusion about APAMs' effectiveness. Additional large, high-quality RCTs are needed. No conclusions can be drawn regarding the comfort of APAMs. A number of technical problems associated with APAMs are related to nurses' improper use of the devices.

Rationale and Aims: Numerous prevalence studies have been conducted. The problem with these studies is that prevalence proportions cannot be compared with each other, because of differences in performance of each survey. There is no agreed standardized method for determining prevalence proportions. This study aimed to develop and pilot a uniform data collection instrument and methodology to measure the pressure ulcer prevalence and to get some insight into pressure ulcer prevalence across different patient groups in Europe., Methods: Pressure ulcer experts from different European countries developed a data collection instrument, which included five categories of data: general data, patient data, risk assessment, skin observation and prevention. A convenience sample of university and general hospitals of Belgium, Italy, Portugal, UK and Sweden participated in the study. In each participating hospital, teams of two trained nurses who collected the data on the wards were established. All patients admitted before midnight on the day of the survey and older than 18 years were included., Results: The data collection instrument and study procedure of the survey were found to be effective by all participants. 5947 patients were surveyed in 25 hospitals in five European countries. The pressure ulcer prevalence (grade 1-4) was 18.1% and if grade 1 ulcers were excluded, it was 10.5%. The sacrum and heels were the most affected locations. Only 9.7% of the patients in need of prevention received fully adequate preventive care., Conclusion: The methodology is sufficiently robust to measure and compare pressure ulcer prevalence in different countries. The pressure ulcer prevalence was higher than expected and relatively few patients received adequate prevention. This indicates that more attention to prevention is needed in Europe.

Aims and Objectives: To evaluate whether postponing preventive measures until non-blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2-4) when compared with the standard risk assessment method., Background: To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non-blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach., Design: Randomized-controlled trial., Methods: Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non-blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non-blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene-urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days., Results: In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2-4) was not significantly different between the experimental (6.8%) and control group (6.7%)., Conclusion: Significantly fewer patients need preventive measures when prevention is postponed until non-blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method., Relevance to Clinical Practice: Using the appearance of non-blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.

Accurate identification of nonblanchable erythema (NBE) is essential in pressure ulcer prevention. This descriptive study assessed interrater reliability between a researcher and trained nurses in observing blanchable erythema and NBE and examined the predictive validity and level of agreement between two observation methods for NBE. Findings suggest that the transparent disk method should be preferred to the finger method. The interrater reliability between the researcher and the nurses was substantial and was higher for the observations at the sacrum than for those at the heels. Educational level and years of nursing experience did not seem to influence interrater reliability.

Background: studies of the effectiveness of alternating pressure air mattresses (APAMs) for the prevention of pressure ulcers are scarce and in conflict., Objective: evaluating whether an APAM is more or equally effective as the standard prevention., Design: randomised controlled trial., Setting and Subjects: patients admitted to 19 surgical, internal, or geriatric wards in seven Belgian hospitals were included if they were in need of prevention of pressure ulcers. To define this need, two methods were used randomly: the Braden Scale or the presence of non-blanchable erythema (NBE)., Methods: 447 patients were randomised into either an experimental or a control group. In the experimental group, 222 patients were lying on an APAM (Alpha-X-Cell, Huntleigh Healthcare, UK). In the control group, 225 patients were lying on a visco-elastic foam mattress (Tempur, Tempur-World Inc., USA) in combination with turning every 4 hours. Both groups had identical sitting protocols., Results: there was no significant difference in incidence of pressure ulcers (grade 2-4) between the experimental (15.6%) and control group (15.3%) (P = 1). There were significantly more heel pressure ulcers in the control group (P = 0.006). There was an interaction effect between the risk assessment method and preventive measures for the development of all pressure ulcers and sacral pressure ulcers., Conclusion: fewer patients developed heel pressure ulcers on an APAM. Patients identified as being in need of prevention based on the presence of NBE had a tendency to develop fewer pressure ulcers on an APAM. Patients identified as being in need of prevention, based on the Braden Scale, appeared to develop more sacral pressure ulcers on an APAM.