Hip fracture and pressure ulcers – the Pan‐European Pressure Ulcer Study – intrinsic and extrinsic risk factors*

Abstract

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

The influence of nutritional risk in elderly patients hospitalized for bone fracture

“…To date, studies have shown that nutritional state moderates the immune response [11], increased risk of pressure ulcers after hip fracture [12], well as longer hospital stays and greater mortality but no differences were noted among the groups regarding functional or cognitive status [13]. The results of the study extend this evidence by showing that nutritional status also moderates the cognitive status of older people.…”

“…Malnutrition also impairs the immune response, increasing the risk of postoperative infections [11]. Poor nutritional status is associated with an increased risk of pressure ulcers after hip fracture [12].…”

Audit of standards of practice in suspected hip fracture

“…Therefore, it seems reasonable that a balance should be struck between the length of time hip-fracture patients must spend in the ED and the pressure-area-assessment and care they receive in this time. Although it may not be practical to transfer the majority of patients with confirmed hip-fractures to orthopaedic wards within 1-2 h of arrival, if long waits within the ED for these patients are expected, practice standards should be improved in terms of providing them with sufficient pain-relief and IV fluids, and in such cases, pressure-areaassessments and care should be carried out for these patients, to minimise their risk of developing further complications (Gunningberg, 2001;Lindholm et al, 2008).…”

Heel ulceration – An exploration of the issues

“…In addition to the general risk factors for pressure ulcer development, there are a number of factors which lead to the heels being at even higher risk of skin breakdown in the orthopaedic patient. Pressure, friction and shear are well documented as the three main extrinsic factors leading to pressure ulcer development (Lindholm et al, 2008;Ousey, 2007;EPUAP, 2005) with the effects of friction thought to be up to five times worse if moisture is present (Grey et al, 2006). The anatomy and position of the heel increase the risk considerably as follows:…”