The National Pressure Ulcer Long-Term Care Study: Pressure ulcer development in long-term care residents

OBJECTIVES: To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents. DESIGN: Retrospective cohort study with convenience sampling. SETTING: Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. PARTICIPANTS: A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry. MEASUREMENTS: Data collected for each resident over a 12-week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs). RESULTS: Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU. CONCLUSION: A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.