Pressure ulcer: Prevalence, incidence, risk factors and the predictive validity of the Braden Q and the Glamorgan risk assessment scales in paediatrics
Background: There is a paucity of research related to the problem of pressure ulcer in paediatrics. Variable incidence and prevalence rates have been reported, although, critically ill paediatric patients have proved to be at higher risk than those in general wards. Few investigations of contributing factors have been based on rigorous methods, and most existing risk assessment scales are either adult-based or depend simply on experience or observation. Objectives: Two separate studies were conducted as part of this research. A prevalence study aimed to measure the prevalence, location and categories of pressure ulcer, as well as pressure ulcer patients’ characteristics in general inpatient paediatric wards. An incidence study was set up to measure the incidence, most affected locations, and categories of pressure ulcer, as well as significant risk factors for pressure ulcer development in critically ill children and neonates. It also aimed to compare the predictive validity of the Braden Q and the Glamorgan RASs in critical care areas. Design: One point prevalence study with a descriptive cross-sectional design and one observational cohort incidence study with longitudinal prospective design were conducted. Setting: All paediatric in-patient wards for the prevalence survey, and four paediatric critical care units (PICU, NICU, GIMU, and GICU) were surveyed in one university-affiliated hospital in Jordan. Paediatric patients in burn, isolation, and psychiatric wards were excluded. Sample: A total of 107 paediatric patients aged from birth up to 18 years old for the prevalence survey, and a total of 212 critically ill paediatric patients without pre- existing pressure ulcer for the incidence study, were recruited. Methods: All patients who met the inclusion criteria were included and assessed for pressure ulcer existence in one day for the prevalence study. Patients eligible for the incidence study were observed up to three times a week for two weeks, then once a week until critical care unit discharge, death, or when the eight week follow-up period ended. In both studies, data was collected by the primary investigator. Main Results: All identified pressure ulcers in both studies were categorised according to the European Pressure Ulcer Advisory Panel classification system. Eight patients (7.5%) had 13 PUs in the prevalence study and, of these, the majority were inpatients in critical units (87.5%, n= 7), had device-related ulcers (75%, n= 6), were female (62.5%, n= 5), younger than one year old (62.5%, n= 5), and had experienced longer stays hospital than pressure ulcer -free patients (Median (IQR)= 11 (27) vs. 4 (7)). Most of the ulcers seen were of partial thickness (category I and II) (n=6, 75%), while only two patients developed category III ulcers (25%), and none had category IV ulcers. If category I PUs were excluded, this would result in a prevalence rate of 2.8% (n= 3). The sites most frequently affected by pressure ulcer were the face (38.5%, n= 5), followed by the occiput and ‘neck and shoulders’, each with 15.3% prevalence (n=2). In the incidence study, 19 patients (9%) developed 29 ulcers, and as low as 5.2% when category I ulcers were excluded. Forty one per cent of pressure ulcers were category I, 48.3% category II, while only 10.3% were category III and none were category IV. The ‘chest and shoulders’ were the most affected areas with ulcers (20.7%, n= 6), followed by areas labelled ‘other’ (which included the arms, back and buttocks, as well as ears) (17.2%, n= 5), and four ulcers were located in each of the mouth, nose, ‘feet and ankles’ areas concurrently (13.8% for each). Based on a multivariate analysis, significant predictors of pressure ulcer were shown to be the mobility sub-item of the Glamorgan scale, and being on mechanical ventilation for 4 days or longer. The Glamorgan scale was more sensitive yet less specific than the Braden Q scale; however, neither of the scales was superior to the other in terms of its predictive validity. Conclusion: Pressure ulcers do exist in Jordanian paediatric patients, and with higher rates among those who are critically ill, thus would have its impact on changing the practice of Jordanian nurses to prevent or reduce its occurrence. Critical care unit paediatric patients most at risk include those who are supported on mechanical ventilation for longer periods, and those who are immobile. Both the Glamorgan and the Braden Q risk scales are valid tools to predict pressure ulcer among critically ill children, but neither is clearly superior to the other.
- PhD