The Incidence Tool

The incidence study tool consisted of five main sections, A, B, C, D, and E, These included the following sets of data:

- Section A): included data related to the ward type, and the patient’s demographical

characteristics, such as, identification number (ID), file number, age and date of birth, gender, newborn gestational age, medical diagnosis, previous hospitalisations, ICU LOS, and date of admission. Also, data related to height, weight, and the vital signs (O2 saturation, blood pressure, heart rate, respiratory rate, and temperature) were added. - Section B): included data about any PU developed during the follow-up period, which is explained thoroughly in section 3.8, the study procedures. The details recorded were the number of the newly located ulcers, their sites and categories. Also, these ulcers were documented in specific tables in the tool, to clarify the exact date on which they were first observed. A further table was added after the pilot study was conducted, to document the date and outcome of each skin assessment, the initial and the follow-up. - Section C): this part included all the pre-determined possible risk factors that were planned to be collected during the incidence study, such as laboratory test results, type of medications administered, medical devices used, skin condition, whether or not the patient was on MV, whether paralysis existed or not, and consciousness level. Most collected Risk factors were in the form of checklist, when applicable, for easier and faster work.

A special table was added after the pilot study was completed to document the medical devices being used, their type and number for each patient.

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- Section D): this part of the tool was filled in on the day of each patient’s admission and it includes the Glamorgan RAS.

- Section E): the final part included the Braden Q RAS. This was also completed on the admission date, as soon as the researcher conducted the skin assessment for each patient at their bedside. For a summary of data collection sheet’ sections see (Figure 3.2) below.

Figure 3.2: Two Data Collection Sheets: Incidence & Prevalence.

3.6.3 The Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale

This scale was developed in 2007 by means of comparing the characteristics of children with PU with those who did not develop PU, and testing the significance of the existing relationships statistically. Further amendments were undertaken in 2008, following an inter-rater reliability study of the newly developed scale. Based on the results of the study, the nutrition sub-item was enhanced by the addition of several indicators of risk in children (Willock et al., 2008).

The final version of the scale has nine sub-items (Appendix 1.10), with varying weightings of the sub-scores for each item. The highest sub-scores were given to immobility and equipment pressing or rubbing on patient skin conditions, with a range between 10 and 20 depending on the condition’s severity, while the remainder of the scale’s sub-items scored 1 if they were found to exist and 0 if absent or not measured.

Prevalence Study Section A: Patients and Ward Charachteristi cs Section B: Prevalence Rate Incidence Study Section A: Patients and Ward Charachteristics Section E: the Braden Q Scale Section B: Incidence Rate Section D: The Glamorgan Scale Section C: Pressure Ulcer Charchteristics

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The total risk score ranges from 0- 42, where ≥10 indicates ‘risk’, ≥15 ‘high risk’, and ≥20 indicates ‘very high risk’ patients.

The main terms used in the Glamorgan RAS, along with its related definitions and risk scores are based on special guidance on using the Glamorgan scale, which has been provided by the scale’s developer (Appendices 3.3 and 3.4).

The Glamorgan Paediatric Risk Assessment Scale (Glamorgan RAS) was chosen for this study for the following reasons:

 It is a newly developed scale for paediatrics which, according to the authors, needs to be tested within new settings and different populations. In this thesis, the scale was tested among a new set of children, namely those who are admitted to critical care units.

 It is the first paediatric RAS which depended on statistical testing of patient data. Other paediatric RASs have either been developed from patient observations, expert opinions or have been modified from adult RASs (Willock et al., 2009, Barnes, 2004, Willock and Maylor, 2004).

 The scale appears to be a promising tool, since it was found to have higher predictive validity compared with other paediatric RASs, even with scales that are frequently used in paediatric; such as the Braden Q scale (Willock et al., 2009, Anthony et al., 2010).

 This scale is the only one in paediatrics that recognises the effect of ‘equipment pressing or rubbing on the skin’ explicitly as a sub-item while giving it a high risk score on the scale. Although there is a newly developed scale, the Braden Q+ P scale (Galvin and Curley, 2012), that names any device attached to patient skin as a category of risk, this was developed only for OR patients. Also, another scale developed by Barnes (2004) lists splints and casts, as well as monitors cables, as risk factors for PU development in children but there is no further mention of other equipment.

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This criterion is important for this study as many authors have pointed out that children’s pressure areas are greatly affected by the use of medical equipment, especially in ICUs (Suddaby et al., 2005, McCord et al., 2004, Zollo et al., 1996). Problems may include tubes pressing or equipment rubbing on children’s skin, and lying for long periods over tubes or even on needle caps, in addition to the folds of the bed linen (Zollo et al., 1996, McCord et al., 2004).

3.6.4 The Braden Q Pressure Ulcer Risk Assessment Scale

This tool was developed in 1996, based on several modifications of the adult Braden scale. As discussed thoroughly in the literature review chapter, the modifications included the addition of a new sub-item (tissue perfusion and oxygenation), and new indicators to clarify existing ones (such as adding Albumin level to the nutrition descriptors).

The scale is composed of seven sub-items: mobility, activity, moisture, tissue perfusion & oxygenation, friction and shear, sensory perception and nutrition. Each sub-item has a score range from 1 to 4, with four being the most favourable and one indicating the worst cases. The total score for each child should range between seven (the highest risk) and 28 (where there is no risk at all) (Quigley and Curley, 1996).

The main terms and categories of the Braden Q RAS, with their related definitions, as used in this research, were based on Noonan et al. (2011). These are presented in (Appendix 1.9).

The Braden Q RAS was chosen for this study for the following reasons:

 It is thought to be a valid and reliable paediatric-specific PU RAS (Noonan et al., 2011).

 It is the most widely used paediatric PU RAS that has been found or discussed in paediatric literature (Loman, 2000, Curley et al., 2003b, Noonan et al., 2006, Suddaby et al., 2005, Noonan et al., 2011). Also, many paediatric

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studies used the original Braden Scale (Samaniego, 2004, Schluer et al., 2009).

 The authors recommend to test this scale with different samples and in different settings. Studies should include children of more diverse age groups and not exclude children with certain conditions such as congenital heart diseases (Curley et al., 2003b, Noonan et al., 2011).

 Taking confidence intervals into account, it was the first scale that tried to define a cut-off risk score based on experts’ clinical judgment (Loman, 2000).