Denis Anthony, for his guidance ... Lastly but no means least, I would like to thank De Montfort University and Al-albayt ... pressure ulcer (P⤠0.05): moving in bed with help, the ability to take a bath ...... were based on risk factors that were proven by research to cause PUs, and have been ...... application of logistic analysis.
Exploring Preventive Interventions and Risk Factors of Hospital-Acquired Pressure Ulcers: A Retrospective Matched CaseControl Design
Ma’en Aljezawi The School of Nursing and Midwifery De Montfort University, Leicester, UK
This thesis is submitted in partial fulfilment of the requirements of De Montfort University for the award of Doctor of Philosophy
May 2011
Dedication This thesis is dedicated to my father, who taught me that the best kind of knowledge to have is that which is learned for its own sake. It is also dedicated to my mother, who taught me that even the largest task can be accomplished if it is done one step at a time.
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Acknowledgments Though only my name appears on the cover of this thesis, a great many people have contributed to its production. I owe my gratitude to all those people who have made this work possible and because of whom my graduate experience has been one that I will cherish forever. I especially want to thank my first supervisor, Prof. Denis Anthony, for his guidance during my research and study. His perpetual energy and enthusiasm in research had motivated all his students, including me. In addition, he was always accessible and willing to help his students with their research. As a result, research life became smooth and rewarding for me. I also want to thank my co-supervisors Mrs. Angela North-Rose and Dr. Jane Rutty for their help and support. I am grateful to Dr. Linda Rafter for her great assistance and help during the data collection phase. Most importantly, none of this would have been possible without the love and support of my brother Zaid and my sisters Amane and Tahane. Furthermore, I would like to express my appreciation to my friends Muhammed AlQadire, Ahmad Tubaisha, Ibrahim Naimi, Murad Magableh, Hamza Aldabbas, Maher Abuzeid, Mohammad Kharabsheh, Mustafa Al-khawaldeh and Osama Abo Alrob. I greatly value their friendship and I deeply appreciate their belief in me. Lastly but no means least, I would like to thank De Montfort University and Al-albayt University for offering me the chance to pursue my doctoral studies. ii
Publications during the study period (2008-2011)
Journal paper: Anthony, DM., Rafter, L., Reynolds, T. and Aljezawi, M. (2011). An evaluation of serum albumin and the sub-scores of the Waterlow score in pressure ulcer risk assessment. Journal of Tissue Viability, in press. Conferences: Aljezawi, M. and Anthony, D. (2010). A retrospective approach to explore effective nursing interventions that prevented hospital acquired pressure ulcers in a Waterlow sub-scores matched cohort. 29th Tissue Viability Society Annual Conference: Looking at things differently: collaboration, evidence and innovation for practice. April 13-14, Telford, UK. (Appendix M) Posters: Aljezawi, M. and Anthony, D. (2010). How did nurses intervene to prevent nosocomial pressure ulcers. Research Degree Student’s Poster Competition, De Montfort University, Leicester, UK, April 2010. (Appendix N)
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Abstract Previous literature showed weak and sometimes contradictory evidence regarding the best interventions to prevent pressure ulcers and the best factors that can serve as predictors for ulceration. The aim of this study was to explore effective interventions and associated risk factors in the area of pressure ulcer. A retrospective approach was used to explore such interventions and risk factors in a more natural clinical environment than found in a prospective study. While retrospective studies have their limitations, one problem of prospective studies, the Hawthorn effect, is not present. In order to meet the aims of the study, a matched case-controlled design was employed. A convenience sampling technique was used to select all patients who matched the study criteria. Two groups of patients were selected. The first group developed pressure ulcer during hospitalization, the other did not. In order to have a sound and robust comparison, each patient from the pressure ulcer groups was matched or at least nearly matched with another patient from the non-pressure ulcer group for a number Waterlow sub-scores. Further criteria for selection included a minimum of three days total length of stay in hospital and being initially free of any pressure ulcer on admission for both of the study groups. Electronic medical records for all patients were revised, and multidimensional data were extracted using a data extraction sheet. Data analyses were carried out using univariate analysis (t-test, Mann-Whitney, Chisquare and Fisher’s exact test) and multivariate analysis (binary logistic regression). In univariate analysis for preventive interventions, the following interventions were significantly associated with pressure ulcer prevention (P≤ 0.05): standard hospital bed, seating cushion, static pressure redistributing mattress, re-positioning every four hours and helping the patient to sit regularly in a chair. When the effect of all interventions was adjusted through the multivariate model, the following interventions were independently associated with prevention: draw sheet, re-positioning every four hours and helping patient to sit regularly in chair (odds ratio = 0.24, 0.06 and 0.13 respectively; P≤ 0.05). In univariate analysis for risk factors related to physical activity and mobility, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): moving in bed with help, the ability to take a bath only in bed, needing two helpers in performing activities of daily living and moving outside bed only by a hoist. When adjusting the effect of all variables related to physical activity and mobility through the multivariate model, only two factors were independently associated with developing pressure ulcer: moving in bed with help and the ability to take a bath only in bed (odds ratio = 7.69 and 3.67 respectively; P≤ 0.05). In univariate analysis for risk factors related to pressure ulcer intrinsic risk factors, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): presence of three underlying medical conditions, dehydration, depression, having a blood iv
transfusion, serum albumin
