Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions

OBJECTIVE: To determine the incidence of pressure ulcers in varied populations, and whether demographic character istics (age, gender, race) and primary diagnosis are factors in pressure ulcer development when the level of risk for developing ulcers is considered. To determine if there is a difference in the type of preventive services prescribed for persons who do or do not develop pressure ulcers when risk is controlled and whether differences can be related to demographic characteristics. DESIGN: Cohort study. SETTING: Two skilled nursing homes, two university operated tertiary care hospitals, and two Veteran's Administration Medical Centers (VAMCs) in Omaha, NE, Durham, NC, and Chicago, IL. PATIENTS: A total of 843 randomly selected patients more than 19 years of age who did not have pressure ulcers on admission to their place of care. Subjects were 63% male, 79% white, and had a mean age of 63 (+/- 16) years. MEASURES: A head-to-toe skin assessment for pressure ulcers recording site and stage of ulcers, scores for the Braden Scale for Predicting Pressure Sore Risk, demographic characteristics (age, sex, race), and primary diagnosis and preventive interventions (turning or repositioning orders and pressure reduction surface) were documented on the patient record. Observations were made every 48 to 72 hours for a minimum of 1 to a maximum of 4 weeks. MAIN OUTCOME MEASURES: Presence/absence and stage of pressure ulcers. MAIN RESULTS: One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care, VAMCs, and nursing homes, respectively. Logistic regression demonstrated that lower Braden Scale scores, older age and white race predicted pressure ulcers; gender was not predictive. Primary diagnoses were not significant predictors of pressure ulcer risk when the Braden Scale score was entered into the regression. Prescription of turning was predicted by Braden Scale scores and by white race, whereas prescription of pressure reduction was predicted by Braden Scale scores, white race, and female sex. CONCLUSIONS: Risk assessment, rather than diagnoses or demographic characteristics, is recommended as the basis for prescriptive decisions. Risk assessment should cue health care providers to make more judicious use of turning and support surfaces to prevent pressure ulcers. Persons who are at risk for pressure ulcers should have turning and pressure reduction surfaces consistently prescribed and implemented. The costs and goals of preventive prescription for those not at risk for pressure ulcers should be considered.