Small study finds 27.7% prevalence of pressure ulcers in paediatric hospitals in Switzerland, with many cases caused by external medical devices
- Correspondence to Lisa M Kohr
University of Pennsylvania School of Nursing, 418 Curie Blvd, Rm 424 Philadelphia, PA 19104, USA
Schlüer and colleagues conducted a multicenter point prevalence study of paediatric pressure ulcers in neonatal intensive care units, paediatric medical and surgical wards, and rehabilitation care settings in four hospitals in Switzerland. The investigators used a convenience sample comprising neonates (including premature infants) and children aged 24 hours to 17 years. They used the European Pressure Ulcer Advisory Panel guidelines and the Braden scale (adult-based) for direct and systematic skin evaluations.
A pressure ulcer prevalence of 27.7% was found in the study sample. By setting, 85% of neonatal intensive care unit, 70% of surgical, 43% of medical and 67% of rehabilitation patients were considered to be at risk for pressure ulcers. Risk factors included a Braden score ≤20, institution and type of ward. Of at-risk patients, 35% were found to have one or more pressure ulcers. The authors concluded that, with the inclusion of grade 1 pressure ulcers from medical devices, the prevalence of pressure ulcers was higher than previously reported (27.7% vs 0.47–23%) and that medical devices pose an additional risk for the development of skin injuries.
This study contributes to a growing body of literature that highlights preventable skin injury in the hospitalised paediatric patient. Iatrogenic skin injuries can prolong hospitalisation and increase the cost of care. Although the timing is not clearly described, the authors report that the majority of pressure ulcers occurred during hospitalisation, with resolution taking up to 6 months in some patients.
There are many methodological concerns regarding this study. First, the study population comprised a diverse paediatric patient population known to be at variable risk for pressure ulcers.1,–,3 Neonates (including premature infants), burn and cardiac patients as well as paediatric patients requiring rehabilitation were included in the study sample. Next, and more importantly, the investigators operationalised pressure ulcers to include both medical device-related skin injuries and immobility-related skin injuries.
The investigators used the Braden scale (adult) to predict pressure ulcer development in their paediatric population. The Braden scale has never been validated in the paediatric population and was not conceptualised to predict device-related skin injury. Incongruent with previous research in the paediatric population, the current study reports one patient with an occipital pressure ulcer.1 Because skin injuries from medical devices and immobility were combined in this study, it should come as no surprise that the Braden scale (adult) performed poorly in predicting device-related skin injury and that the anatomical locations of the ‘pressure ulcers’ were dissimilar to those given in previous reports. Most (43%) of this study's pressure ulcers were located in areas that “could not be precisely specified” owing to “tubes, splints and monitoring cables”.
This study highlights the need for clinical researchers to use clear operational definitions. The risk of skin injuries and nursing interventions to prevent them are different for medical devices and immobility. The Braden Q scale is a valid and reliable paediatric-specific risk assessment tool for immobility-related pressure ulcers and has been tested in infants and children aged 3 weeks to 8 years.4 The Braden Q scale was derived from a Braden and Bergstrom physiologically based conceptual framework that is population independent.5 A German translation of the Braden Q scale is available.6 Medical devices can potentially compress a patient's skin and cause a device-related skin injury. One does not need a tool to predict device-related skin injury; the risk is simply that the device is present.
Future point prevalence studies should enroll a sufficient sample size to allow for subgroup analysis, differentiate and provide separate analyses for device-related skin injuries and immobility-related pressure ulcers and describe the medical devices associated with skin injury.
Competing interests None.