Pres­sure injuries prevention is better than solv­­ing of their complications


Předcházení dekubitům je lepší než řešení jejich důsledků

Cíl:

Cílem studie bylo analyzovat výskyt dekubitů u pa­cientů hospitalizovaných na I. chirurgické klinice FN u sv. An­ny v Brně v letech 2015– 2017, zjistit závislost na neurologických komorbiditách a u osmi nemocných s výskytem pozičních dekubitů zhodnotit možnosti ovlivnění jejich vzniku.

Metodika:

Retrospektivní analýza dat z nemocničního informačního systému a elektronického nástroje (i-hojeni.cz). Statistická analýza byla provedena pomocí Pearsonova chí-kvadrátu, hladina významnosti 0,05.

Výsledky:

V období 2015– 2017 podstoupilo operační výkon 9 550 nemocných z 11 028 hospitalizovaných pa­cientů. Nově se vytvořil dekubitus u 115 pa­cientů, kteří byli hospitalizováni (62 žen a 53 mužů), z toho 104 operovaných. Průměrný věk těchto pa­cientů byl 81,61 (36– 97) let; průměrný index tělesné hmotnosti (body mass index; BMI) 24,93; průměrná doba hospitalizace 23,4 dní. Doba od přijetí nemocných k operaci byla 2,82 (0– 16) dní. Průměrně byl výskyt 1,41 dekubitů na pa­cienta. Nejčastější lokalizace dekubitů byly na hýždích a patách. Nebyl zjištěn statisticky významný vztah mezi BMI a vznikem dekubitů (p > 0,05). Věk pa­cientů a délka hospitalizace naopak souvisely s výskytem dekubitů (p < 0,05). Neprokázali jsme statistickou závislost mezi vznikem dekubitu u operovaných nemocných a přítomností neurologické anamnézy v předchorobí. Celkem zemřelo 15 nemocných, ale 9 z nich zemřelo na příznaky sepse bez přímé souvislosti s dekubitální lézí. Zvláštní skupinu s dekubity tvořilo osm nemocných, kteří byli přijatí k hospitalizaci s pozičními traumaty, z nichž šest zemřelo na rozvoj septického stavu v důsledku dekubitálních lézí.

Závěr:

Přes všechna preventivní opatření vznikají dekubity u chirurgicky léčených pa­cientů zejména v souvislosti s anamnézou neurologické dia­gnózy (71,30 %). Prevenci vzniku dekubitů je třeba uplatňovat nejen v nemocnicích a v zařízeních sociálních služeb, ale i v domácnostech. Následky pádů, zejména seniorů s velmi nekvalitním sociálním zázemím, jsou mnohdy zcela fatální.

Klíčová slova:

dekubitus – dekubitální léze – incidence – traumatický pacient – poziční dekubitus

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Authors: L. Veverková;  K. Krejsová;  M. Kacafírková;  M. Reška;  P. Vlček;  J. Žák;  J. Konečný;  I. Čapov
Authors‘ workplace: First Department of Surgery, Faculty of Medicine, Masaryk University and St. Anne´s University Hospital, Brno, Czech Republic
Published in: Cesk Slov Neurol N 2018; 81(Supplementum 1): 32-37
Category: Original Paper
doi: 10.14735/amcsnn2018S32

Overview

Aim:

Target of this study was to analyse occur­rence of pres­sure ulcers (PUs) in patients hospitalized at First Department of Surgery of St. An­ne’s University Hospital between 2015 and 2017, identify their dependency on neurological comorbidities. Especial­ly in group of eight patients with developed position PUs to analyse the pos­sibility to influence their origin.

Methodology:

Retrospective analysis of the data from the hospital information system and an electronic tool (i-hojeni.cz). Statistical analysis was car­ried out by means of Pearson’s chi-square test, level of significance 0.05.

Results:

In the period 2015– 2017 in total 9,550 patients out of 11,028 hospitalized patients underwent surgery. The PUs developed dur­­ing hospitalization in 115 hospitalized patients (62 women and 53 men), out of which 104 underwent surgery. Average age of these patients was 81.61 (36– 97) years of age, the average body mass index (BMI) was 24.93 and average length of hospitalization was 23.4 days. The time between admis­sion to hospital and surgery was 2.82 (0– 16) days. On average, there occur­red 1.41 PUs per patient. The most frequent location of PUs were heels and buttocks. We found no statistical­ly significant relation between BMI and occur­rence of PUs (p > 0.05). On the contrary, the patients’ age and length of hospitalization related to the occur­rence of PUs (p < 0.05). We proved non-statistic relation between development of pres­sure ulcer in operated patients and existence of neurological anamnesis. In total, 15 patients died, nevertheless 9 of them died with symp­toms of sepsis with no direct relation to the PU lesions. A special group of evaluated patients were eight patients who had PUs after position trauma. The six of them died (75%) of septic development due to PUs.

Conclusion:

In spite of all preventive measure, PUs develop in surgical­ly treated patients, especial­ly those with neurological dis­eases in patient history (71.30%). Measures prevent­­ing development of PUs need to be applied not only in hospitals and institutes of social care but also in home care. Consequences of fal­ls –  especial­ly of elderly with frequently insuf­ficient social background may be ultimately fatal.

Key words:

decubitus – pressure lesion – incidence – trauma patient – position pressure ulcers

Introduction

Statistic clearly shows that approximately 2– 5% of surgical interventions result in development of infection. These infections may have serious impact not only on patient’s health and their return to active lives but also on hospital operations and increased financial burden for the healthcare providers. Up to 5% cases of infections as­sociated with health care may result in death of a patient. This group of patients includes also patients suf­fer­­ing from pres­sure ulcers (PUs) development dur­­ing their hospitalization [1– 3]. In spite of all preventive measures the PUs still occurs, and they will keep doing, so we speak here about so-cal­led non-avoidable hospital acquired PUs. Their treatment is extremely costly and lengthy. As a result of fal­ling, so-cal­led “position trauma“ can develop –  it is a muscle damage with consequent rhabdomyolysis, damage of nerves, cardiovascular system with skin defect development. This condition is a consequence of any long-term imposed position, e. g. in elderly with poor social background. Worsened recovery of defect may be caused by a number of factors such as age, nutrition conditions, cardiovascular dis­eases, infection, other comorbidities but also neurological dis­eases.

Materials and methods

Retrospective analysis of data from the hospital information system and an electronic tool (i-hojeni.cz) dur­­ing the period between 2015 and 2017. Statistical analysis was car­ried out by means of Pearson’s chi--square test with level of significance of 0.5.

Results

Out of the total number of 11,028 patients hospitalized at First Department of Surgery of St. An­ne’s University Hospital between 2015 and 2017 in total 9,550 (86.59%) patients underwent surgery.

Within the monitored period, new PUs developed dur­­ing hospitalization in First Department of Surgery in 115 patients, out of which 104 underwent surgery. An independent group consisted of eight patients who were admitted with the position trauma symp­toms. Average age of patients was 81.61 (36– 97) years and the group consisted of 62 women and 53 men (Tab. 1; Fig. 1, 2).

1. Group characteristics.
Group characteristics.

Patient´s gender.<br>
Obr. 1. Pohlaví pacientů.
1. Patient´s gender.
Obr. 1. Pohlaví pacientů.

Patients’ age (distribution in given years).<br>
Obr. 2. Věk pacientů (distribuce v daných letech).
2. Patients’ age (distribution in given years).
Obr. 2. Věk pacientů (distribuce v daných letech).

Body mass index (BMI) was on average 25.37 (16.7– 41.2) kg/ m2. Average length of hospitalization was 25.7 (3– 187) days. Period between admis­sions until the operation lasted on average for 2.79 (0– 16 days). Although the factor of period between admis­sions until the day of operation seem to predict the development of PUs, in fact it did not in our group of patients.

Amongst patient suf­fer­­ing from PUs we observed occur­rence of neurological dia­g­noses in patient history data. Regard­­ing the fact that we had supposed that operated patients with neurological dia­gnosis are exposed to higher risk of development of PUs. We identified increased percentage of occur­rence of PUs in 71.30% (with 82 patients). Most typical­ly these were patients fol­low­­ing a stroke, patients suf­fer­­ing from Alzheimer dis­ease or other type of cerebral insuf­ficiency. Conditions fol­low­­ing the brain tumour surgery or cervical spondylosis occur­red only in three cases (Fig. 3).

Relation between diagnoses with occurrence of pressure ulcers and neurological
diagnosis in anamnesis with operated patients 2015–2017.<br>
Obr. 3. Vztah mezi diagnózou s výskytem dekubitů a neurologickou diagnózou
v anamnéze u operovaných nemocných 2015–2017.
3. Relation between diagnoses with occurrence of pressure ulcers and neurological diagnosis in anamnesis with operated patients 2015–2017.
Obr. 3. Vztah mezi diagnózou s výskytem dekubitů a neurologickou diagnózou v anamnéze u operovaných nemocných 2015–2017.

Pres­sure ulcers were most typical­ly ranged between grade 1 and 2 (average of 1.68).

Amongst patients suf­fer­­ing from position trauma the grades of PUs were between II. and IV. category.

Number of PUs per one patient in our group was 1.42. The patients with position traumas suf­fered from up to five locations or three locations with signs of pres­sure lesions. Fig. 4, 5 show PUs in two patients.

Patient, 73-years-old man, living alone, visited by son. Found unconscious in his garden. Admitted to hospital with position trauma,
dehydration and rhabdomyolysis. After admission, hypotension, hyperthermia and large position trauma with max. changes on lateral dorsal
side of torso and lower limbs. Patient is a chronic ethylic (A–D).<br>
Obr. 4. Pacient, 73letý muž, žije sám, navštěvuje ho syn. Tři dny ležel na zahradě v bezvědomí, při přijetí hypotenze, hypertermie a rozsáhlé
trauma s maximem změn v oblasti trupu laterodorzálně l.dx. a dolních končetin. Přijat jako poziční trauma s dehydratací a rhabdomyolýzou
k terapii. Pacient závislý na alkoholu (A–D).
4. Patient, 73-years-old man, living alone, visited by son. Found unconscious in his garden. Admitted to hospital with position trauma, dehydration and rhabdomyolysis. After admission, hypotension, hyperthermia and large position trauma with max. changes on lateral dorsal side of torso and lower limbs. Patient is a chronic ethylic (A–D).
Obr. 4. Pacient, 73letý muž, žije sám, navštěvuje ho syn. Tři dny ležel na zahradě v bezvědomí, při přijetí hypotenze, hypertermie a rozsáhlé trauma s maximem změn v oblasti trupu laterodorzálně l.dx. a dolních končetin. Přijat jako poziční trauma s dehydratací a rhabdomyolýzou k terapii. Pacient závislý na alkoholu (A–D).

Patient, 64-years-old female, casus socialis. Moves around on the wheelchair, condition after amputation of right lower limb above
knee (A–C).<br>
Obr. 5. Pacientka, 64 letá žena, casus socialis. Pohybuje se na invalidním vozíku, stav po amputaci pravé dolní končetiny ve stehně, defekt
na hýždi (A–C).
5. Patient, 64-years-old female, casus socialis. Moves around on the wheelchair, condition after amputation of right lower limb above knee (A–C).
Obr. 5. Pacientka, 64 letá žena, casus socialis. Pohybuje se na invalidním vozíku, stav po amputaci pravé dolní končetiny ve stehně, defekt na hýždi (A–C).

Most frequently, the PUs occur­red in buttocks and then on the heels (Fig. 6).

Location of pressure ulcers in hospitalized patients in 2015–2017.<br>
Obr. 6. Lokalizace dekubitů u hospitalizovaných nemocných v letech 2016–2017.
6. Location of pressure ulcers in hospitalized patients in 2015–2017.
Obr. 6. Lokalizace dekubitů u hospitalizovaných nemocných v letech 2016–2017.

In relation with occur­rence of PUs within the observed group of patients we focused on significance of some of the risk factors (BMI, age, length of hospitalization, comorbidity).

We compared the monitored values with the number of finished hospitalization in our department, the average age 58.15, BMI 26.5 with average length of hospitalization –  5.92 days. We did not find any statistical­ly significant relation between BMI and de­velopment of PUs (p > 0.05). Age of patients and length of hospitalization showed statistical­ly significant relation with occur­rence of PUs.

Very serious and probably absolutely fundamental factor predict­­ing development of PUs was in 71.30% occur­rence of neuro­logical dis­ease in anamnesis in trauma patients and patients fol­low­­ing the chest surgery.

Out of the total 62 trauma-operated patients, in 52 patients we identified serious neurological dis­eases prior development of trauma (Tab. 2).

2. Group characteristics – patient with pressure ulcers.
Group characteristics – patient with pressure ulcers.

Similar situation occur­red in a group of 16 patients suf­fer­­ing from PUs after chest surgery. In 75% patients fol­low­­ing the chest surgery and consequently developed PUs, there was a neurological dis­ease in their patient history (cerebral palsy, condition after meningioma surgery, paraplegia fol­low­­ing stroke, spinal compres­sion, Parkinson dis­ease, polyneuropathy). Even though it is a relatively small percentage of patients in our presented group, it is obvious that in cases of patients suf­fer­­ing from PUs there were more frequent neurological dia­gnosis in their patient history. Statistical evaluation is presented in Tab. 3.

3. Relation of the neurological diagnose in history and surgical diagnose and pressure ulcers. Χ2 = 2.53, df = 2. Χ2/df =1.27, P (Χ2 > 2.36) = 0.2814.
Relation of the neurological diagnose in history and surgical diagnose and
pressure ulcers. Χ<sup>2</sup> = 2.53, df = 2. Χ<sup>2</sup>/df =1.27, P (Χ<sup>2</sup> > 2.36) = 0.2814.

It is obvious that presence of neurological dia­gnosis represents a factor which shows very significant within our group.

Out of all analysed patients (n = 115) suf­fer­­ing from PUs 15 patients died (13.0%) (Fig. 7). Death was caused by sepsis, nevertheless only with 6 patients the sepsis was caused by and related to PUs. All these cases involved patients with position trauma. Out of total 8 patients with PUs and position trauma, 6 died –  that is 75%. These were some of the “most expensive patients” in terms of costs of care. For example one patient was admitted after the fall with sun stroke and severe dehydration with neces­sary artificial lung ventilation with comorbidities, as­ses­sed grade 4 by American Society of Anaesthesiologists (ASA) physical status clas­sification, have demonstrated a cor­relation between ASA clas­sification and perioperative mortality. Average ASA value of our analysed patients was 3.17.

Chart of death of patients suffering
from pressure ulcers.<br>
Obr. 7. Graf úmrtí pacientů s dekubity.
7. Chart of death of patients suffering from pressure ulcers.
Obr. 7. Graf úmrtí pacientů s dekubity.

With other patients who died n = 9 (8.4%), the cause of death did not directly relate to PUs. These are patients operated for severe symp­toms of peritonitis who suf­fered severe bronchopneumonia or urinary sepsis, osteomyelitis etc. fol­low­­ing the surgery.

Discus­sion

Each developed pres­sure sore brings unpleasant complication both for the patient and the nurs­­ing staf­f. Treatment of developed PUs leads to prolonged hospitalization of the patient and, consequently, to increased financial burden for the system [1,2]. Compensation for hospitalization at the standard ward shows clearly descend­­ing tendency (1,260 CZK per one day between day 1 and 3; contrary to 586 CZK per day start­­ing from day 13 until the release of patient from hospital). Subjectively, PUs cause pain relat­­ing to increase occur­rence of hospital-acquired infections (worsen­­ing both local and general health status of the patient includ­­ing the threat of development of sepsis) [3,4].

In our retrospective study we confirmed that development of PUs does not relate to BMI of the patients, which nevertheless does not represent suf­ficient information concern­­ing the nutrition status of the patient and may rather be used as a general value to as­sess the risk of PUs development. In case of other monitored variables, we proved dependence between the patient’s age and development of PUs or between development of PU and length of hospitalization and neurological dia­gnosis in patient history.

Our group of patients suf­fer­­ing with post-operative PUs is rather small compared to total number of hospitalised patients and patients undergo­­ing surgery at the First Department of Surgery proves high quality of care provided by the medical and nurs­­ing staf­f.

Frequently, a com­mon place fall of a polymorbid patients, who live alone and lack suf­ficient physical power to manage to care for themselves, may result in fatal consequences.

Accord­­ing to the data from the Institute of Health Information and Statistics of the Czech Republic (IHIS CZ), occur­rence of death caused by PUs is on nation-wide range very low –  only 5.6% [5]. In our group it was in 75% patients fol­low­­ing the position trauma.

Our department employs various method of local wound treatment, includ­­ing the negative pres­sure wound ther­apy [6]. We need to realize that, apart from the local ther­apy, in majority of cases we are unable to treat PUs of higher grade without cor­respond­­ing systemic ther­apy. In case the patients are not treated systemic but local­ly, their over­all health status may on contrary worsen. Wounds that are not treated adequately may cause significant suf­fer­­ing to patients and have negative impact on physical, social, emotional and financial aspects of their lives [7– 9]. General­ly, we can state that higher age and longer stay in hospital is linked with increased occur­rence of PUs [10]. Prevention of fal­ls represents a basic precaution of any trauma at home and prevention measure linked to the pos­sible complication dur­­ing hospitalization.

Conclusion

Occur­rence of PUs in our department in hospitalized patients and patients undergo­­ing surgery is repeatedly very low, which testifies very good quality and profes­sional care for the patients. Undoubtedly, the benefits from the use of a specialized wound monitor­­ing tool and database within our hospital information system, includ­­ing implementation of preventive measures in line with World Union of Wound Healing Societies recom­mendations. Our study proved relation between development of PUs and existence of neurological dis­ease in patient undergo­­ing surgery and in their history at our department. Measures prevent­­ing development of PUs need to be applied not only in hospitals and institutes of social care but also in-home care setting. Consequences of fal­ls and trauma –  especial­ly in elderly with frequently insuf­ficient social background may be ultimately fatal and thus lead­­ing to the more complications dur­­ing the hospitalization includ­­ing PUs occur­rence.

The authors declare they have no potential The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.conflicts of interest concerning drugs, products, or services used in the study.

doc. MUDr. Lenka Veverková, Ph.D.

First Department of Surgery

St. Anne’s University Hospital

Pekarská 664/53

656 91 Brno

Czech Republic

e-mail: lenka.veverkova@fnusa.cz

Accepted for review: 28. 6. 2018

Accepted for print: 16. 8. 2018


Sources

1. World Health Organization. WHO Guidelines for safe surgery 2009: safe surgery saves lives. [online]. Geneva: WHO Press 2009. Available from URL: http:/ / whqlibdoc.who.int/ publications/ 2009/ 9789241598552_eng.pdf.

2. National Institute for Health and Clinical Excel­lence. Appendix H: Methodology checklists: economic evaluations. The guidelines manual. London: NICE 2009; 195: 200– 207.

3. Gottrup F, Apelqvist J, Price P et al. Outcomes in control­led and comparative studies on non-heal­­ing wounds: recom­mendations to improve the quality of evidence in wound management. J Wound Care 2010; 19(6): 237– 268. doi: 10.12968/ jowc.2010.19.6.48471.

4. Pokorna A, Saibertova S, Vasmanska S et al. Regis­ters of pres­sure ulcers in an international context. Cent Eur J Nurs Midw 2016; 7(2): 444– 452. doi: 10.15452/ CEJNM.2016.07.0013.

5. Mandal A. Role of topical negative pres­sure in pres­sure ulcer management. J Wound Care 2007; 16(1): 33– 35. doi: 10.12968/ jowc.2007.16.1.26987.

6. Haesler E (ed). National Pres­sure Ulcer Advisory Panel, European Pres­sure Ulcer Advisory Panel, Pan Pacific Pres­sure Injury Al­liance. Prevention and treatment of pres­sure ulcers: quick reference guide. Perth: Cambridge Media 2014.

7. Black JM, Cuddigan JE, Walko MA et al. Medical device related pres­sure ulcers in hospitalized patients. Int Wound J 2010; 7(5): 358– 365. doi: 10.1111/ j.1742-481X.2010.00699.x.

8. Pokorna A, Benešová K, Mužik J et al. The pres­sure ulcers monitor­­ing in patiens with neurological dis­eases –  analyse of the National Register of Hospitalized Patient. Cesk Slov Neurol N 2016; 79 (Suppl 1): S8–  S14. doi: 10.14735/ amcsn­n2016S8.

9. Haesler E (ed). National Pres­sure Ulcer Advisory Pa-nel, European Pres­sure Ulcer Advisory Panel and Pan Pacific Pres­sure Injury Al­liance. Prevention and Treat­ment of Pres­sure Ulcers: Clinical Pract­ice Guideline. Osborne Park: Cambridge Media 2014.

Labels
Paediatric neurology Neurosurgery Neurology
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