Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

Objective To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. Design Multicentre prospective cohort study. Setting UK hospital and community settings. Participants inclusion Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). Exclusion Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. Follow-up Twice weekly for 30 days. Primary and secondary outcome measures Development and time to development of one or more category ≥2 PUs. Results Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). Conclusions This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development.

[1]  Isabelle L Smith,et al.  Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures , 2015 .

[2]  C. Dealey,et al.  Pressure ulcer related pain in community populations: a prevalence survey , 2014, BMC Nursing.

[3]  Jane Nixon,et al.  A new pressure ulcer conceptual framework , 2014, Journal of advanced nursing.

[4]  David Machin,et al.  Design of studies for medical research , 2013 .

[5]  C. Rivers,et al.  The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients , 2013, BMC Nursing.

[6]  Jane Nixon,et al.  Patient risk factors for pressure ulcer development: systematic review. , 2013, International journal of nursing studies.

[7]  D. Aarsland,et al.  Assessment and treatment of pain in people with dementia , 2013, Nature Reviews Neurology.

[8]  Jane Nixon,et al.  Patient-reported pressure ulcer pain: a mixed-methods systematic review. , 2011, Journal of pain and symptom management.

[9]  M. Pittler.  Systematic Reviews in Health Care: Meta‐analysis in Context , 2010 .

[10]  Jane Nixon,et al.  Impact of Pressure Ulcers on Quality of Life in Older Patients: A Systematic Review , 2009, Journal of the American Geriatrics Society.

[11]  D. Langemo,et al.  Pressure ulcer pain: a systematic literature review and national pressure ulcer advisory panel white paper. , 2009, Ostomy/wound management.

[12]  P. Cochat,et al.  Et al , 2008, Archives de pediatrie : organe officiel de la Societe francaise de pediatrie.

[13]  M. Harrison,et al.  The symptom of pain with pressure ulcers: a review of the literature. , 2008, Ostomy/wound management.

[14]  A. Radford,et al.  Prevalence of silver resistance in bacteria isolated from diabetic foot ulcers and efficacy of silver-containing wound dressings. , 2008, Ostomy/wound management.

[15]  S. Pocock,et al.  Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies , 2007, BMJ : British Medical Journal.

[16]  S. Bond,et al.  Skin alterations of intact skin and risk factors associated with pressure ulcer development in surgical patients: a cohort study. , 2007, International journal of nursing studies.

[17]  K. Craig,et al.  An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons , 2007, The Clinical journal of pain.

[18]  M. Drummond,et al.  A systematic review and economic model of the effectiveness and cost-effectiveness of methylphenidate, dexamfetamine and atomoxetine for the treatment of attention deficit hyperactivity disorder in children and adolescents. , 2006, Health technology assessment.

[19]  E. A. Nelson,et al.  Pressure relieving support surfaces: a randomised evaluation. , 2006, Health technology assessment.

[20]  Jane Nixon,et al.  Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial , 2006, BMJ : British Medical Journal.

[21]  Jill Hayden,et al.  Evaluation of the Quality of Prognosis Studies in Systematic Reviews , 2006, Annals of Internal Medicine.

[22]  M. Berger,et al.  Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools , 2006, BMC geriatrics.

[23]  Douglas G Altman,et al.  Dichotomizing continuous predictors in multiple regression: a bad idea , 2006, Statistics in medicine.

[24]  N. Christakis,et al.  Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the Steering Committee of the European Association for Palliative Care. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[25]  Tom Defloor,et al.  Pressure ulcers: validation of two risk assessment scales. , 2005, Journal of clinical nursing.

[26]  R. Reed,et al.  Low Serum Albumin Levels, Confusion, and Fecal Incontinence: Are These Risk Factors for Pressure Ulcers in Mobility-Impaired Hospitalized Adults? , 2003, Gerontology.

[27]  Erik Buskens,et al.  Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers , 2002, BMJ : British Medical Journal.

[28]  Olga Vitek,et al.  Screening for pressure ulcer risk in an acute care hospital: development of a brief bedside scale. , 2002, Journal of clinical epidemiology.

[29]  R. Frantz,et al.  Pressure ulcers in community-based older adults receiving home health care. Prevalence, incidence, and associated risk factors. , 1999, Advances in wound care : the journal for prevention and healing.

[30]  A. Schultz,et al.  Etiology and incidence of pressure ulcers in surgical patients. , 1999, AORN journal.

[31]  S. Mason,et al.  A sequential randomised controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. , 1998, International journal of nursing studies.

[32]  N. Bergstrom,et al.  Multi‐site Study of Incidence of Pressure Ulcers and the Relationship Between Risk Level, Demographic Characteristics, Diagnoses, and Prescription of Preventive Interventions , 1996, Journal of the American Geriatrics Society.

[33]  J. Concato,et al.  Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. , 1995, Journal of clinical epidemiology.

[34]  R. Allman,et al.  Pressure ulcer risk factors among hospitalized patients with activity limitation. , 1995, JAMA.

[35]  W. Sauerbrei,et al.  Dangers of using "optimal" cutpoints in the evaluation of prognostic factors. , 1994, Journal of the National Cancer Institute.

[36]  L. Lipsitz,et al.  A Longitudinal Study of Risk Factors Associated with the Formation of Pressure Ulcers in Nursing Homes , 1994, Journal of the American Geriatrics Society.

[37]  D. Collett.  Modelling Binary Data , 1991 .

[38]  P. Hinds,et al.  A triangulation of methods and paradigms to study nurse-given wellness care. , 1987, Nursing research.

[39]  F. Harrell,et al.  Regression models for prognostic prediction: advantages, problems, and suggested solutions. , 1985, Cancer treatment reports.

[40]  Prevention and Treatment of Pressure Ulcers : Clinical Practice Guideline , 2017 .

[41]  S. Masonb,et al.  A sequential randomised controlled trial comparing a dry Viscoelastic polymer pad and standard operating table Mattress in the prevention of post-operative pressure sores , 2005 .

[42]  N. Bergstrom,et al.  The Braden Scale for predicting pressure sore risk. Nursing Research, 36 (4), 205-210 , 1988 .

[43]  Douglas G Altman,et al.  Systematic reviews of evaluations of prognostic variables , 2001, BMJ : British Medical Journal.