Czynniki ryzyka rozwoju odleżyn u chorych podczas hospitalizacji

Introduction

Patients with limited activity, in progressive phase of cancer, lying in bed, or sitting in wheelchairs are particularly vulnerable to bedsore development. Bedsores belong to wounds with multifactorial aetiology, and a significant role in their development is played also by skin condition [1-4]. In literature numerous risk factors are listed increasing the probability of bedsore development: external factors (Table 1) – independent of patients’ health status but connected with the care environment, often dependent on the caregivers; and internal (Table 2) – hardly reversible, strictly related to the patient’s health status [1, 3, 5].
Registration of bedsore development risk among patients with bedsore ulcers, as well as registration of those with bedsores developed during hospitalisation, enables the preparation and use of preventive, caring, and healing tools [6]. These data are necessary for planning individual care schedules and focusing them directly on modification, and even on elimination, of bedsore development risk factors before their influence makes irreversible changes such as necrosis and reduction of tissues [7].
The aim of this work was to identify chosen bedsore development risk factors among patients with bedsores that developed during hospitalisation.

Material and methods

The tests were carried out during one year in four chosen wards of a hospital in Bydgoszcz (wards of: general surgery, intensive medical care, neurology, and neurosurgery). Among all patients hospitalised in the mentioned wards a bedsore development risk assessment was made according to the Doreen Norton scale. Analysis underwent all patients endangered of bedsores registers and medical documentation of these patients (disease history and care). The criteria of introducing the tests were: bedsore development risk (≤ 14 Norton points at least in one assessment), bedsore appearance during hospitalisation, and at least five-day period of patient observation. The exclusion criterion was bedsore appearance in the moment of starting hospitalisation.
Statistical analysis was performed using Pearson’s 2 test, Student’s t-test, and Fisher’s exact test. The quotient of bedsores development chances was calculated together with 95% trust interval. All statistical tests were carried out at a significance level of 5%.
The Bioethical Committee of Collegium Medicum in Bydgoszcz agreed to carry out the tests.

Tested group characteristics

The tested group consisted of 733 patients with bedsore development risk. This group was divided into two subgroups. The first group consisted of 95 patients (12,96%) among whom bedsores developed during hospitalisation, and the second group consisted of 638 patients among whom bedsores did not develop (control group). The average age for the group with bedsores was 70.42 ±14.31 years (min 21, max 97), and for the group without bedsores: 63.24 ±15.75 years (min 18, max 99). Men constituted 56.9% of the tested group (Table 3). A significant majority of the patients lived in the city (70.7%). Only 14.3% of them lived alone.

Results

To identify bedsore development risk factors during hospitalisation, demographic and clinic characteristics were compared for a group of 95 patients with bedsores that developed during hospitalisation and for patients without bedsores (n = 638).
Among the group of patients with bedsores there were significantly more people hospitalised because of circulatory system diseases, and significantly fewer people hospitalised for neurological or oncological diseases (Table 4).
Among patients with bedsores that developed in hospital, in comparison to patients without bedsores, there were significantly more people among which the additional diagnosis was: arterial hypertension (p = 0.049), diabetes (p = 0.031), arteriosclerosis (p < 0.001), chronic obstructive pulmonary disease (COPD) (p < 0.001), asthma (p = 0.006), and the following appeared: limited movement (p < 0.001), higher temperature (p < 0.001), and oedema (p < 0.001).
Patients who developed bedsores during hospitalisation were more often (on the verge of statistical significance) hospitalized urgently (Table 5).
Patients with and without bedsores did not differ significantly considering sex, place of residence, living alone or with family, education level, stroke appearance, spinal cord injuries, and multiple organ injury (p > 0.05).
Among constant variables, significant intergroup differences concerned the length of hospitalisation, patient’s age, protein and haemoglobin concentration levels, and parameters assessed in the Norton scale (Table 6). Patients with bedsores that developed in hospital were significantly longer hospitalised and were significantly older. Moreover, in this group, significantly lower protein concentration during hospitalisation, significantly lower haemoglobin concentration in the moment of admission, and low haemoglobin concentration during hospitalisation were stated.
Patients with bedsores that developed during hospitalisation were characterised by significantly lower physical state, mental state, mobility, and incontinence score in the Norton scale. Moreover, patients with bedsores that developed during hospitalisation had lower (on the verge of statistical significance) levels of activity assessed in the Norton scale.
However, significant intergroup BMI differences were not stated.
Variables in which significant or close to statistical significance intergroup differences were stated, were analysed in a one-dimensional model of logistic regression concerning their role as bedsore development risk factors during hospitalisation.
Among discrete variables, significant factors of bedsore development risk during hospitalisation were (starting from the strongest): limited condition level, higher temperature and oedema during hospitalisation, COPD, arteriosclerosis and asthma, circulatory system diseases, and diabetes. Moreover, risk factors close to significance turned out to be: urgent admission and arterial hypertension. However, significant factors that did not have any influence on bedsore development during hospitalisation were (starting from the strongest): oncological and neurological reasons for hospitalisation (Table 7).
From constant variables, significant bedsore development risk factors were (starting from the strongest): long hospitalisation time and higher patient’s age. The significant factors protecting against bedsore development were (starting from the strongest): higher level of mobility assessed in the Norton scale, higher level of physical state assessed in the Norton scale, higher level of haemoglobin and protein during hospitalisation, higher score of incontinence and mental state in the Norton scale, higher level of haemoglobin during admission, and higher total score in the Norton scale (Table 8).
Variables that turned out to be significant risk/protection factors in one-dimensional analysis of logistic regression were analysed in a multi-dimensional model. In this way their significance as independent risk/protection factors proved to be: limited condition level and oedema appearance during hospitalisation (risk factors), as well as neurological hospitalisation and higher protein concentration during hospitalisation (protection factors).

Discussion

In the literature there are many proofs that chronic disease appearance (internal factors) is not neutral in the aetiopathogenesis of bedsore development. The great danger, however, is connected with the appearance of general symptoms of basic disease and undesirable actions and complications connected with treatment methods [8-12]. The most common risk factors are: fever, undernourishment, anaemia, immobilisation, perfusion disorders, pain, traumas, neurological diseases, long surgical procedures, incontinence, diabetes, and skin damage [1, 8, 9, 12-14]. Researchers in their publications state that the risk factors that appear most often as independent predictors of bedsore development concern three basic branches: mobility/activity of patients, tissue perfusion disorders (including diabetes), and skin state. Moreover, among patients treated in intensive care wards, risk factors include also: the length of stay in the intensive care ward, mechanical ventilation presence and the duration of its usage, usage of interrupted haemodialysis or constant vain-vain hemofiltration, and sedative medications. They conclude that there is no single factor that can explain the risk of bedsore development, but rather the complicated influence of many factors increases the probability of bedsore development [15, 16].
In the presented material, co-occurrence of chronic diseases (diabetes, arterial hypertension, asthma, COPD, arteriosclerosis) and higher temperature were significant factors of bedsore development during hospitalisation. Limited condition level, however, and oedema occurrence, based on statistical analysis, were stated as independent bedsore development risk factors.
Lowering tissue perfusion may be an important bedsore development factor undergoing assessment. In this research an attempt was made to identify it on the basis of haemoglobin concentration. In double assessment (on the day of admission and the lowest concentration of all assessed during hospitalisation), between average values of haemoglobin in groups of patients with and without bedsores, there is a statistically significant difference. In this research the haemoglobin concentration among patients with bedsores developed during hospitalisation was on average 11.33 ±2.69 g/dl (min 4.7, max 18.9). However, the lowest values during the whole stay were on average at the level of 8.71 ±2.33 g/dl (min 4.7, max 15.4). Other researchers stated that haemoglobin concentration in a group of 87 people with bedsores was at an average of 7.6 ±1.6 g/dl (min 5.4, max 11.6) [17]. In other work with reference to patients treated in a surgical ward, it was stated that those who were in need of supplementary blood were more prone to bedsore development (close to significant statistical dependence; p = 0.076) [18]. In tests of patients treated in an intensive care ward, differences in haemoglobin concentration among both groups of patients were not significant [19].
Higher concentration of protein during hospitalisation was taken as a significant factor of protection against bedsore development. Similar conclusions can be drawn also from other tests [19, 20].
Such factors as long hospitalisation time or older age of the patient are commonly stated as predictors for bedsore development [1, 3, 10, 12, 21, 22]. They are often connected with a physical condition disorder, up to the total immobilisation state. Both parameters constitute important elements of assessing patients’ state, both during admission and during the hospitalisation period. This procedure of nursery assessment of bedsore development risk ease scales [1, 23, 24]. One of the recommended tools for this is the Norton point scale. In the tested group significantly lower scores of parameters such as: physical and mental state, mobility and incontinence, and total score in the Norton scale were seen in patients with bedsores that developed during hospitalisation (p < 0.05). Average point values in terms of patients’ activity were on the verge of statistical significance (p = 0.065). Similar results were gained during tests carried out in 2009 in the same place, among group of people hospitalised in a general surgery clinic. Patients among whom bedsores developed scored significantly lower average point values in the Norton scale than those among whom bedsores did not develop [25]. Also, Terekeci et al. received results suggesting that low values in the Norton scale among patients treated in an intensive care ward increased the risk of bedsore development [19].
On the basis of nursery assessment of bedsore development risk profile, care-therapeutic activities towards every patient have to be planned and realized. Among individually picked actions, we have to take into account, mainly, encouragement to move and passive removal of pressure by changing the patient’s position more often [1, 8, 26, 27].

Conclusions

Occurrence of co-morbidities (arterial hypertension, diabetes, asthma, COPD) and symptoms directly connected with health status (higher temperature, oedema, mobility limitation) in a significant way influences bedsore development during hospitalisation. Low values of laboratory parameters (protein and haemoglobin concentration) are predictors of bedsore development.
Bedsore development risk decreases with the increase of point values of parameters assessed in the Norton scale.

The authors declare no conflict of interest.

References

1. Szewczyk M, Sopata M, Jawień A, et al. Prophylaxis and bedsores treatment. Leczenie Ran 2010; 7: 79-106.
2. Medical Advisory Secretariat. Management of chronic pressure ulcers: an evidence-based analysis. Health Quality Ontario. Ont Health Technol Assess Ser 2009; 9: 1-203.
3. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, Haesler E (ed.). Cambridge Media, Perth, Australia 2014.
4. Stafiej JM, Szewczyk MT. When prevention fails... A problem not only bedsores hospital. Pieleg Chir Angiol 2011; 3: 171-174.
5. de Araújo TM, de Araújo MF, Caetano JÁ, et al. Nursing diagnoses for patients at risk of developing pressure ulcer. Rev Bras Enferm 2011; 64: 671-676.
6. Kiełbasa L. Procedure of bedsore prophylactic as a tool of nurse care quality assessment. Pieleg Chir Angiol 2010; 3: 85-89.
7. Cwajda-Białasik J, Mościcka P, Szewczyk MT. Selected aspects of prevention of pressure ulcers. Pieleg Chir Angiol 2017; 11: 41-48.
8. Anders J, Heinemann A, Leffmann C, et al. Decubitus ulcers: pathophysiology and primary prevention. Dtsch Arztebl Int 2010; 107: 371-381.
9. Bansal Ch, Scott R, Stewart D, et al. Decubitus ulcers: A review of the literature. Int J Dermatol 2005; 44: 805-810.
10. Włodarczyk B. Prophylaxis and bedsore treatment among patients with hematopoietic system diseases. Hematology 2011; 2: 349-362.
11. Smith M. A comprehensive review of risk factors related to the development of pressure ulcers. J Orthop Nurs 2003; 7: 94-102.
12. Ferreira Chacon JM, Nagaoka C, Blanes L, et al. Pressure Ulcer Risk Factors Among the Elderly Living in Long-term Institutions. Wounds 2010; 22: 106-113.
13. Campbell C, Parish LC. The decubitus ulcer: Facts and controversies. Clin Dermatol 2010; 28: 527-532.
14. Tschannen D, Bates O, Talsma A, et al. Patient-specific and surgical characteristics in the development of pressure ulcers. Am J Crit Care 2012; 21: 116-125.
15. Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud 2013; 50: 974-1003.
16. Lima Serrano M, González Méndez MI, Carrasco Cebollero FM, et al. Risk factors for pressure ulcer development in Intensive Care Units: Systematic review. Med Intensiva 2017; 41: 339-346.
17. Alderden J, Whitney JD, Taylor SM, et al. Risk Profile Characteristics Associated With Outcomes of Hospital-Acquired Pressure Ulcers: A Retrospective Review. Crit Care Nurse 2011; 31: 30-43.
18. Cierzniakowska K, Łabuńska A, Szewczyk MT, et al. Analysis of chosen factors influencing on bedsores development. Leczenie Ran 2010; 7: 71-77.
19. Terekeci H, Kucukardali Y, Top C, et al. Risk assessment study of the pressure ulcers in intensive care unit patients. Eur J Intern Med 2009; 20: 394-397.
20. Ülker Efteli E, Yapucu Günes Ü. A prospective, descriptive study of risk factors related to pressure ulcer development among patients in intensive care units. Ostomy Wound Manage 2013; 59: 22-27.
21. Eberlein-Gonska M, Petzold T, Helaß G, et al. The incidence and determinants of decubitus ulcers in hospital care: an analysis of routine quality management data at a university hospital. Dtsch Arztebl Int 2013; 110: 550-66.
22. Cox J. Predictors of pressure ulcers in adult critical care patients. Am J Crit Care 2011; 20: 364-375.
23. Defloor T, Grypdonk MF. Validation of pressure ulcer risk assessment scales: a critique. J Adv Nurs 2004; 48: 613-621.
24. Sopata M, Tomaszewska E, Głowacka A. Pressure ulcers – risk assessement and prevention. Pieleg Chir Angiol 2007; 1: 165-169.
25. Cierzniakowska K, Szewczyk MT, Łabuńska A, et al. The assessment of bedsores development on the basis of Doreen Norton scale. Leczenie Ran 2011; 8: 7-13.
26. Peterson MJ, Gravenstein N, Schwab WK, et al. Patient repositioning and pressure ulcer risk – Monitoring interface pressures of at-risk patients. J Rehabil Res Dev 2013; 50: 477-488.
27. Leijon S, Bergh I, Terstappen K. Pressure ulcer prevalence, use of measures, and mortality risk in an acute care populations a quality improvement project. Wound Ostomy Continence Nurs 2013; 40: 469-474.