National Pressure Ulcer Long Term Care Study

Data are from 1996-1997.  Funded by Ross Products Division of Abbott Laboratories and Hill-Rom, Inc.  The goals of this practice based evidence (PBE) study were to determine those resident and treatment factors that are associated with both development and treatment of pressure ulcers.

Description of the National Pressure Ulcer Long-Term Care Study. Susan D. Horn, PhD, Stacy A. Bender, MS, RD, Nancy Bergstrom, RN, PhD, Abby S. Cook, BS, RD, Maree L. Ferguson, PhD, RD, Holly L. Rimmasch, MSN, CCM, Siobhan S. Sharkey, MBA, Randall J. Smout, MS, George A. Taler, MD, and Anne C. Voss, RD, PhD. JAGS 50:1816–1825, 2002 (November).

Objectives: To describe and provide baseline data from The National Pressure Ulcer Long-Term Care Study (NPULS).

Design: Retrospective cohort study of detailed resident characteristics, treatments, and outcomes using convenience sampling.

Setting: One hundred nine long-term care facilities throughout the United States.

Participants: Two thousand four hundred twenty adult residents aged 18 and older, with a length of stay of 14 days or longer and who were at risk of developing a pressure ulcer, as defined by a Braden Scale for Predicting Pressure Sore Risk

Measurements: More than 500 characteristics were obtained for each resident over a 12-week period. This paper describes the NPULS database with respect to the resident (sex, age, diagnoses, severity of illness scores, Braden Scale score, activities of daily living, cognitive ability, mobility, bowel or bladder incontinence, laboratory values, nutritional assessment, and pressure ulcer assessment documentation), treatment (nutritional interventions, pressure relieving devices, incontinence interventions, protective devices, turning schedules, and pressure ulcer treatments), and outcome variables (pressure ulcer development and healing, pressure ulcer and systemic infection, changes in nutritional status, and discharge disposition) associated with pressure ulcers. Descriptive statistics and bivariate associations were used for preliminary analyses of resident, treatment, and outcome characteristics.

Results: The average age ± standard deviation was 79.7 ± 14.2; 70% of the residents were female. Fifty-three percent of residents (n = 1,293) were at risk of developing a pressure ulcer but never developed one during the study (Group 1), 19% developed a new pressure ulcer during the study (n = 457) (Group 2), 22% had an existing pressure ulcer (n = 534) (Group 3), and 6% had an existing pressure ulcer and developed a new ulcer during the study (n = 136) (Group 4). Residents who developed a new pressure ulcer (Group 2) were more likely to be female, older, cognitively impaired, and immobile than residents who had an existing pressure ulcer (Group 3).

Conclusions: This baseline study describes the NPULS database with respect to the resident, treatment, and outcome variables associated with pressure ulcers. Future studies will focus on multivariate analyses for risk factor prediction of pressure ulcer development and pressure ulcer healing. Research-based pressure ulcer prevention and treatment protocols can then be developed.

The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents. Susan D. Horn, PhD, Stacy A. Bender, MS, RD, Maree L. Ferguson, PhD, RD, Randall J. Smout, MS, Nancy Bergstrom, RN, PhD, George Taler, MD, Abby S. Cook, BS, RD, Siobhan S. Sharkey, MBA, Anne Coble Voss, PhD, RD. JAGS 52:359–367, 2004 (March).

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.

The National Pressure Ulcer Long-Term Care Study: Outcomes of Pressure Ulcer Treatments in Long-Term Care. Nancy Bergstrom, PhD, RN, Susan D. Horn, PhD, Randall J. Smout, MS, Stacy A. Bender, MS, RD, Maree L. Ferguson, PhD, RD, George Taler, MD, Abby C. Sauer, MPH, RD, Siohban S. Sharkey, MBA, and Anne Coble Voss, PhD, RD. JAGS 53:1721–1729, 2005 (October).

Objectives: To identify resident, wound, and treatment characteristics associated with pressure ulcer (PrU) healing 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: Eight hundred eighty-two residents, aged 18 and older, with length of stay of 14 days or longer, who had at least one Stage II to IV PrU.

Measurements: Data collected for each resident over a 12-week period included resident characteristics, treatment characteristics, and change in PrU area. Data were obtained from medical records, Minimum Data Set, and other records.

Results: Two multiple regression models, one for each stage grouping (Stage II, Stage III and IV), were completed. The area of Stage II PrU was reduced more with moist (F=21.91, P<.001) than with dry (F=13.41, P<.001) dressings. PrUs cleaned with saline or soap showed less decrease in area (F=12.34, P<.001) than PrUs cleaned with other cleansers such as antiseptic, antibiotic, or commercial cleansers. Change in area of Stage III and IV PrUs was related to sufficient enteral feeding (F=5.23, P=.02), enteral feeding without higher acuity levels (F=3.94, P=.048), size of PrU (very large (F=120.89, P=.001) and large (F=27.82, P=.001)), and type of dressing (moist (F=14.70, P<.001) and dry (F=5.88, P=.02)). Stage III and IV PrUs increased in area when debrided (F=5.97, P=.02). The overall models were significant (Stage III and IV, F=20.30, coefficient of determination (R²)=0.06, P<.001; Stage II, F=40.28, R²=0.13, P<.001) but explained little of the variation in change in PrU area.

Conclusions: In this sample of nursing facility residents, use of moist dressings (Stage II, Stage III and IV) and adequate nutritional support (Stage III and IV) are strong predictors of PrU healing.

RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. Horn, Susan D. PhD; Buerhaus, Peter PhD, RN; Bergstrom, Nancy PhD, RN; Smout, Randall J. MS . American Journal of Nursing. 105(11):58-70, November 2005.

Objectives: A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents.

Methods: In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time.

Results: More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes.

Conclusions: The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.

Cost Analysis of Nursing Home Registered Nurse Staffing Times. David A. Dorr, MD, Susan D. Horn, PhD and Randall J. Smout, MS. JAGS 53:840–845, 2005(May).

Objectives: To examine potential cost savings from decreased adverse resident outcomes versus additional wages of nurses when nursing homes have adequate staffing.

Design: A retrospective cost study using differences in adverse outcome rates of pressure ulcers (PUs), urinary tract infections (UTIs), and hospitalizations per resident per day from low staffing and adequate staffing nursing homes. Cost savings from reductions in these events are calculated in dollars and compared with costs of increasing nurse staffing.

Setting: Eighty-two nursing homes throughout the United States.

Participants: One thousand three hundred seventy-six frail elderly long-term care residents at risk of PU development.

Measurements: Event rates are from the National Pressure Ulcer Long-Term Care Study. Hospital costs are estimated from Medicare statistics and from charges in the Healthcare Cost and Utilization Project. UTI costs and PU costs are from cost-identification studies. Time horizon is 1 year; perspectives are societal and institutional.

Results: Analyses showed an annual net societal benefit of $3,191 per resident per year in a high-risk, long-stay nursing home unit that employs sufficient nurses to achieve 30 to 40 minutes of registered nurse direct care time per resident per day versus nursing homes that have nursing time of less than 10 minutes. Sensitivity analyses revealed a robust set of estimates, with no single or paired elements reaching the cost/benefit equality threshold.

Conclusions: Increasing nurse staffing in nursing homes may create significant societal cost savings from reduction in adverse outcomes. Challenges in increasing nurse staffing are discussed.

Comparison of Air-Fluidized Therapy with Other Support Surfaces Used to Treat Pressure Ulcers in Nursing Home Residents. Rachel F. Ochs, MD, JD; Susan D. Horn, PhD; Lia van Rijswijk, RN, MSN, CWCN; Catherine Pietch, BS, MT, CCRA; and Randall J. Smout, MS. Ostomy/Wound Management 2005 (February);51(2):38-68.

To provide empirical evidence comparing pressure ulcer healing rates between different support surfaces, data were analyzed from eligible residents with pressure ulcers (N = 664) enrolled in the National Pressure Ulcer Long-Term Care Study, a retrospective pressure ulcer prevention and treatment study. Support surfaces were categorized as: Group 1 (static overlays and replacement mattresses), Group 2 (low-air-loss beds, alternating pressure, and powered/non-powered overlays/mattresses), and Group 3 (air-fluidized beds). Calculation of healing rates, using the largest ulcer from each resident, found mean healing rates greatest for air-fluidized therapy (Group 3) (mean = 5.2 cm2/week) versus Group 1 (mean =1.5 cm2/week) and Group 2 (mean = 1.8 cm2/week) surfaces (P = 0.007). Healing rates also were assessed using 7- to 10-day “episodes”; each ulcer generated separate episode(s) that included all ulcers when residents had multiple ulcers. Mean healing rates were significantly greater for Stage III/IV ulcers on Group 3 surfaces (mean = 3.1 cm2/week) versus Group 1 (mean = 0.6 cm2/week) and Group 2 (mean = 0.7 cm2/week) surfaces (Group 2 versus Group 3: P = 0.0211). This finding persisted for ulcers with comparable initial baseline areas (20 cm2 to 75 cm2) on Group 2 and Group 3 surfaces; healing improved on Group 3 surfaces (+2.3 cm2/week) versus Group 2 surfaces (-2.1 cm2/week, P = 0.0399). Residents on Group 3 (6 out of 82; 7.3%) and Group 1 (47 out of 461; 10.2%) surfaces had fewer hospitalizations and emergency room visits than those on Group 2 surfaces (23 out of 121; 19.0%, P = 0.01) despite significantly greater illness in residents on Group 2 and 3 versus Group 1 surfaces (P <0.0001). Despite limitations inherent in retrospective studies, ulcers on Group 3 surfaces versus Groups 1 and Group 2 surfaces had statistically significant faster healing rates (particularly for Stage III/IV ulcers) with significantly fewer hospitalizations and emergency room visits (Group 3 versus Group 2), despite significantly more illness in residents on Group 2 or Group 3 versus Group 1 surfaces. Episode analyses — providing greater power, uniform treatment duration, and comparable baseline sizes — confirmed these findings. Air-fluidized support surfaces represent great healing potential that justifies further exploration. KEYWORDS: nursing homes, support surfaces, pressure ulcer healing, retrospective, multi-center study. This study was funded by a grant from Hill-Rom.