The mean age of patients in the study population was 77.3 years (SD = 7.8 years; ). Patients in the study population were primarily women (60.2%) and Black (71.4%), and most had lived at home with others before admission (58.3%). Approximately equal numbers of patients were recruited from each hospital. The median length of stay for this sample was 5 days (interquartile range = 3–8 days), whereas the median time between hospital admission and the study examination was 48 hours (interquartile range = 44.2–60.5 hours). Few patients in the study population had surgical procedures (2.5%) or stayed in an intensive care unit or postanesthesia care unit (13.9%) before the study examination.
Characteristics of Study Population (N = 792)
The study sample included 29 patients with both preexisting and hospital-acquired pressure ulcers, 36 patients with one or more preexisting pressure ulcers but no hospital-acquired pressure ulcers (14 of whom had at least one Stage 2+ ulcer), 166 patients with one or more hospital-acquired pressure ulcers but no preexisting pressure ulcers (71 of whom had at least one Stage 2+ ulcer), and 561 patients with no pressure ulcers. Thus, most patients in the study population had no pressure ulcers (88.3%). Among those with pressure ulcers, it was most common to have just one pressure ulcer (7.4% of the study population), although 1.9% had two pressure ulcers and 2.4% had at least three pressure ulcers at examination.
Approximately 17% of patients in the study cohort were classified as being at risk of pressure ulcers (Norton score ≤14). There were also substantial proportions of patients with the individual pressure ulcer risk factors examined. For example, 24.5% of patients in the study cohort had an intermediate or high risk of nutrition-related complications. Almost 21% of patients in the study cohort were not oriented fully to person, place, and time, whereas 18.9% of patients in the study cohort had urinary incontinence, fecal incontinence, or both (not tabulated).
Fifteen percent of patients had one or more preventive devices for pressure ulcers in use (). Frequencies for individual devices were 0.4% for replacement mattress, 3.6% for mattress overlay, 2.9% for heel protectors, 1.1% for chair cushion, 11.4% for positioning pillows, and 0.6% for another preventive device.
Frequency of Device Use by the Presence of Risk Factors
All examined risk factors were associated significantly with device use (). In particular, the presence of pressure ulcers was associated with the use of pressure ulcer preventive devices (p < .001). Patients with both hospital-acquired and preexisting pressure ulcers were most likely to have a preventive device (75.9%). Frequency of device use was lower for those with hospital-acquired pressure ulcers than for those with preexisting pressure ulcers (43.2% vs. 50.0% for those with Stage 2+ pressure ulcers, respectively, and 32.4% vs. 64.3% for those with Stage 1 pressure ulcers only). Patients with Stage 1 hospital-acquired pressure ulcers were less likely to have preventive devices in use than were those with Stage 2+ hospital-acquired pressure ulcers. The opposite association with stage was observed for preexisting pressure ulcers.
There was a gradient of decreasing frequency of preventive device use with decreasing pressure ulcer risk (indicated by lower Norton scores) and with decreasing risk of nutrition-related complications. Fifty-one percent of patients classified as at risk by the Norton score (≤14) had a preventive device in use (p < .001). Even in the highest pressure ulcer risk group (defined as Norton score 5–10), only 62.4% of patients had a preventive device in use. Similarly, among patients at high risk of nutrition-related complications, only 36.3% had a preventive device. Greater comorbidity, presence of incontinence, disorientation, and more ADL dependencies were associated with preventive device use (p < .001 for each). Less than half of the patient population were using preventive devices in the high-risk category of each of these risk factors. Higher age was associated also with use of preventive devices (p = .011), but gender (p = .13) and Black race were not (p = .37).
In the unadjusted model, there was a strong association between pressure ulcer type and stage and preventive device use, but this association was no longer significant once the model was adjusted for Norton score and the other covariates. For example, the OR for device use comparing those with both types of pressure ulcers with those with no pressure ulcers was 26.7 (95% confidence interval [CI] = 10.9–65.4) before adjustment but only 1.2 (95% CI = 0.5–2.9) after adjustment. In contrast, the association between Norton score category and preventive device use was strong regardless of adjustment for covariates including pressure ulcer type and stage. Those with Norton scores of 5–10 had a much higher odds of preventive device use (adjusted OR = 41.8, 95% CI = 14.0–124.6) compared with the odds of those with scores of 19–20. The adjusted OR for the other at-risk category (Norton scores 11–14) was also large (OR = 21.1, 95% CI = 8.4–52.9). Comorbidity (OR = 1.1, 95% CI = 1.0–1.3), urinary incontinence (OR = 2.5, 95% CI = 1.3–5.1), and having six ADL dependencies (OR = 2.2, 95% CI = 1.1–4.4) were the only other variables that remained significantly associated with device use in the multivariable models.
The association between Norton at-risk status and use of preventive devices was strongest among those with no pressure ulcers (OR = 9.3, 95% CI = 4.8–18.2; ) or with hospital-acquired pressure ulcers only (OR = 9.4, 95% CI = 1.4–64.2). The association was also strong among those with preexisting pressure ulcers only (OR = 6.0, 95% CI = 2.5–14.2). Among those with both hospital-acquired and preexisting pressure ulcers, there was no significant association between Norton at-risk status and preventive device use. The interaction between Norton at-risk status (≤14 vs. >14) and pressure ulcer type was not significant (χ2[3, n = 739] = 3.36, p = .34, not tabulated).
FIGURE 2 Odds ratio (95% confidence interval) for use of preventive devices comparing those with Norton score ≤14 with those with Norton score >14, stratified by the presence and type of pressure ulcers. Details of statistical model are provided (more ...)
The frequency of documentation of pressure ulcers in the patient record was low (). Only 67.5% of patients who had pressure ulcers at the skin examination had any pressure ulcer indicated in the patient record. Pressure ulcers were more likely to be noted in the patient record or discharge documentation if the pressure ulcer at examination was Stage 2 or higher, if the pressure ulcers were preexisting (rather than hospital-acquired), or if the patient had both types of pressure ulcers. Documentation was also more frequent as the number of pressure ulcers present at the examination increased.
Frequency of Documentation of Pressure Ulcers