Data collection procedures:

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Data collection was conducted on two separate dates, with one month in between, for the two independent studies which formed this research (prevalence and incidence). Each one is explained separately below. The data collection was accomplished by one rater, the researcher. Many studies have shown that the number of raters seems not to affect the prevalence rate (Kottner et al., 2009a, Kottner et al., 2009b). In fact, the author believed that the quality of the researcher’s training is more important than the number of the raters involved in assessing PU (Kottner et al., 2009b).

Furthermore, having only one rater conduct the study was thought to be beneficial in terms of improving reliability, by decreasing the variation that could exist if more than one rater was used. The use of a sole rater would improve consistency in reporting the existence of PUs, their numbers, sites and categories. Also, it is not unusual to have one rater in PU incidence and prevalence studies (Kim et al., 2009, Chan et al., 2009).

3.8.1 The Prevalence Study:

Initial preparations took place before this part of the study was carried out, to ensure an appropriate allocation of time and resources. On the day of the study, the researcher requested a list of all admitted paediatric inpatients aged from birth up to 18 years and this was provided by the information technology department (ITD) of the hospital. The included wards were surveyed sequentially, based on their level in the hospital, starting with the lower ground up to the highest floor level.

Each floor had four wards, each was visited as applicable, depending on the admitted cases. Any child who was not available at his or her bedside at the time of visiting the ward was excluded from the study, although, in fact, this criterion only resulted in one child being excluded.

After ethical approval was obtained from the target hospital (Appendix 2.2), the survey was conducted over one day. On this particular day, the researcher completed the physical assessment for the skin of each eligible child (as per the criteria mentioned earlier). This took place at the bed side, in no longer than 10 minutes. Consent forms were obtained from parents (Appendix 2.9), and from children (Appendix 2.11)

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according to their age groups as applicable. Verbal consent was also taken immediately before the assessment was started, to ensure that the child and parents understood the study, and still agreed to participate.

The skin assessment involved examining the entire skin, and especially the areas which, according to previous literature, are the most severely affected (head, especially occiput and face, sacrum, heels and a long side any attached medical devices to the child skin). The researcher carried out the assessment in the presence of the child’s bedside nurse, to assure that the patient’s and researcher’s rights were preserved. Also, the nurse was able to help with repositioning patients if this was difficult for the researcher to do alone, either because of the child’s weight, or due to the existence of complicated medical equipment being in place.

The categorisation of PU-cases in this study was based on the EPUAP classification system (2009) (Appendix 1.7). After each assessment was carried out, the researcher completed the sections of the prevalence data collection sheet. Data documented for each child included general information about the ward, patient demographics, and the characteristics, number, category and location of each identified pressure ulcer. These details were recorded immediately to reduce the possibility of missing or inaccurate data documentation. Other data were derived from patients’ hospital files (medical records) as needed, before the skin assessment was initiated.

3.8.2 The Incidence study:

This study’ data were collected over five month’s period from December 2011- May 2012, with a follow-up period of up to eight weeks. This time period was chosen based on the findings of other relevant PU incidence studies. One study which was carried out in three PICUs revealed that most ulcers developed in the first two days after admission (57%, n= 113), and all except one of the identified ulcers had developed before day eight (Curley et al., 2003a).

Another multi-site incidence study which was conducted in neonatal ICUs revealed that the vast majority of PUs had developed in the first 21 days following admission (78.6%,

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n= 11) and, of these, six developed within the first week (54.5%) (Fujii et al., 2011). One more incidence study of PU in adult patients observed that more than 80% of the developed ulcers had occurred in the first 40 days after admission (n= 36). Of these, around half developed within the first 20 days (40.1%, n= 18) (Onigbinde et al., 2012). Children who had been admitted to the hospital’s ICUs (PICU, NICU, GICU, and GIMU) were included in this incidence study. Any child admitted to the ICU on the intended date of study was included and was examined within 24 hours of their admission, a protocol which has been shared by several previous PU incidence studies (Curley et al., 2003a, Chan et al., 2009, Kim et al., 2009).

Within the first 24 hours of a child’s admission to one of the previously mentioned ICUs, the researcher conducted an initial skin assessment (no. 0). This assessment helped the researcher in:

- Detecting the presence or absence of PU, taking into consideration that any child who was found with PU at the initial assessment was to be excluded from this study.

- Collecting demographical and general data. This also depended on gathering data from patients’ files, and extracting laboratory test results from the hospital’s computer system.

- Recording details of any presumed predictors of patients’ risk of developing PU during an ICU stay.

- Calculating the risk score for each child of developing PU, by employing both the Glamorgan and Braden Q RASs. This subsequently aided in classifying children into ‘risk’, ‘high risk’, ‘very high risk’, and ‘no risk’ groups according to the Glamorgan scale, or into ‘risk’ or ‘no risk’ groups according to the Braden Q scale.

For each child to be included in this study, he/she needed to have at least one follow-up skin assessment after the initial assessment, to allow time to address any changes in the child’s skin condition (i.e. the development of PU). Therefore, the total number of assessments carried out ranged from 2 to 12, including the initial one (no. 0). The first

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week of the child’s stay would include three skin assessments on fixed dates (no. 0; the first one in the day of admission, no.1, on the third day following admission; and no. 2, the third one, held on day number seven).

The second week included three similar assessments (nos. 3, 4, & 5), and then weekly assessments were conducted until the patient died, was discharged from the ICU, or the follow-up period finished without PU developing (up to 12 assessments by the end of week eight). This protocol of setting out when the assessments would occur was adopted from a similar study by Curley et al (2003b). This particular study was thought to be the most relevant to the current work since it was implemented in PICU. The timescale for assessments was also based on previous literature which recommended carrying out the initial skin assessment within the first 24 hours (Curley et al., 2003b, Chan et al., 2009).

In addition, on the recommendation of other relevant studies, the initial assessment was conducted within 48 to 72 hours of admission (Reddy, 1990, Quigley and Curley, 1996) seeing as the second assessment (no. 1) subsequent to the initial admission assessment (no. 0) was performed on the third day following the child’s admission to the ICU. Each of the studies cited above has claimed that the time between the cause and the actual appearance of PU is up to three days. However, even in the adult literature, there is no agreement about the best date to detect PU, especially those categorised I, although it is generally thought that a PU of category II or higher, would take three to five days to develop until it could be observed on the skin (Lindan, 1961, Reddy, 1990, Dinsdale, 1973).

In this thesis, the majority of PUs were observed during the first observation day following the initial assessment (42%, n=8) and the vast majority of PU-patients had developed ulcers by the first and second observations (73.7%, n= 14), thus data collected during the initial observations were used to compare the PU- and PU-free patient groups. Similar findings were noted in (Curley et al., 2003b), in which data was analysed based on the first observation, where 57% of ulcers were observed.

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The skin assessment was a complete assessment of the child’s skin from head to toe based on the researcher’s judgment with the naked eye. The outcome the researcher was interested in throughout the frequent assessments was whether the child would develop PU or not.

Even when it was noticed that a child had developed PU before the end of the follow-up period, the assessments were continued, so that any changes in the developed PU (for example, its category or any healing) and/or the development of further PUs could be recorded.

Any PU observed during the study was documented with details of the ulcer’s category, location and numbers. If an ulcer was found covered with Eschar, it was considered category IV, as recommended by the EPUAP (EPUAP and NPUAP, 2009).

By the end of the initial skin assessment the researcher had completed all the sections in the incidence data collection sheet, except for section B (PU characteristics table and follow-up assessment table) which was filled in on the first day, and continued to be throughout the follow-up period.