and-after study of the effect of linens constructed of ... · and-after study of the effect of...

28 ostomy wound management® April 2013 www.o-wm.com

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a retrospective, nonrandomized, Before-and-after study of the effect of Linens Constructed of synthetic silk-like Fabric on Pressure ulcer IncidenceAnnette Smith, MSN, RN; Laurie L. McNichol, MSN, RN, GNP, CWOCN; Mary Anne Amos, MSN, RN; Gayle Mueller, MBA, RN, MHA; Tracy Griffin, BSB; Joe Davis; Lora McPhail, BSN, RN; and Terry G. Montgomery, PhD

abstractA new, synthetic, silk-like fabric was developed for the purpose of providing bedding and patient gowns that manage moisture, friction, and shear when used between the patient and the healthcare support surface that may affect the de-velopment of pressure ulcers (PUs). A retrospective study was conducted to compare the incidence of hospital-acquired PUs in patients admitted to Telemetry, Urology, and Intensive Care Units before and after hospital linens were changed from standard to the synthetic (intervention) linens. Patient medical record data were abstracted for a period 12 weeks before (control) and 12 weeks following the linen change (intervention). Patient demographic information, Braden Risk Scale score, and PU status and stage were abstracted for a total of 659 patients in the control and 768 patients in the intervention groups. No significant differences in patient weight, age, gender distribution, PU risk (Braden scale scores), or proportion of PUs on admission between groups were found. The most common comorbidity was hypertension (n = 981, 68.7%). On admission, the percentage of patients with PUs in the control and intervention groups was 9.9% (σ = 0.3) and 8.7% (σ = 0.3), respectively (P = 0.23). Average length of stay was 5.6 days in the control and 5.2 days in the interven-tion groups (P = 0.08). Sixty-eight (68) of 659 patients (10.3%) in the control and 19 out of 768 patients in the intervention group (2.5%) developed one or more PUs (P <0.001) for an incidence of 11.5% in the control and 3.1% in the intervention group. At discharge, 136 PUs were present in the control and 64 were present in the intervention group (P <0.001). The significant differences in the incidence of hospital-acquired PUs between the two groups suggest that linen type affects PU risk. Additional controlled clinical studies in high-risk patient populations are warranted.

Keywords: retrospective clinical study, bedding and linens, pressure ulcer, prevention, incidence

Index: Ostomy Wound Management 2013;59(4):28–34

Potential Conflicts of Interest: Ms. McPhail and Dr. Montgomery are employees of Precision Fabrics Group, Inc, Greensboro, NC.

Ms. Smith is Vice President of Nursing; Ms. McNichol is a Clinical Nurse Specialist/WOC Nurse; Ms. Amos is a Director, Telemetry/Urology Units; and Ms. Mueller is a Director, Intensive Care Unit, Wesley Long Community Hospital, Greensboro, NC. Ms. Griffin is Director of Supply Chain Operations and Mr. Davis is Assistant Director of Supply Chain Operations, Cone Health System, Greensboro, NC. Ms. McPhail is a Nurse Consultant and Dr. Montgomery is a Vice President, Precision Fabrics Group, Inc, Greensboro, NC. Please address correspondence to: Terry Montgomery, PhD, Precision Fabrics Group, Inc, 301 North Elm Street, Suite 600, Greensboro, NC 27401; email: [email protected].

Healthcare bed linens and patient gowns come into inti-mate contact with patients treated in a hospital setting.

Hospital bed linens and patient gowns are typically made from cotton-blend fabrics that are inherently deficient in keeping patients’ skin dry and in minimizing skin friction and shear.1-3 Investigating the role of healthcare textile mate-rials in the formation and prevention of pressure ulcers in a retrospective study of the medical records of 22 residents in a

long-term care (LTC) facility, Zhong et al1 found that immo-bility contributed to prolonged interaction between the skin and bedding fabrics, producing correlations between differ-ent fabric surfaces and the incidence of pressure ulcers. In a biomechanical study of healthcare bed linens and underpads, Biesecker et al2 determined the coefficient of friction of wet cotton bedding was almost two times greater than dry bed-ding. In a separate biomechanical study, Pryczynska et al3 DO N

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LInens and Pressure uLCer InCIdenCe

highlighted the value of synthetic healthcare bed linens in reducing the effects of moisture, friction, and shear on bed-bound patients. The ability to rapidly wick moisture, trans-port moisture vapor, and dry quickly are important factors in helping fragile skin stay dry and minimizing maceration.1,2 In their overview of moisture-associated skin damage, Gray et al4 described how moisture from perspiration, incontinence, or wound exudate increases friction and shear forces on the skin, which weakens the intercellular bonds in the epider-mal layers, causing maceration and epidermal ulceration. As demonstrated in a biomechanical study5 of interface-pressure distribution between various fabrics and a skin-simulating material, friction, the adherent force resisting shearing of the skin, has been shown to result in abraded areas of the dermis, as when patients move or are moved across the coarse surface of a cotton bed sheet.

A new synthetic silk-like fabric technology (DermaTher-apy®, Precision Fabrics Group, Inc, Greensboro, NC) was developed for the purpose of providing bedding and patient gowns that are cleaner, drier, and smoother than conventional cotton-blend healthcare fabrics. Continuous-filament yarns are woven to produce a silk-like fabric that provides a smooth interface that may help minimize irritation and abrasion of fragile skin. To provide a quick-drying interface between the patient and the support surface, much like performance ath-letic apparel, very fine filaments within the continuous-fila-ment yarns create micro-channels that are designed to wick moisture away and dry the bedding and skin more quickly than cotton fabrics.6

A 6-month prospective, nonrandomized, controlled trial7

compared the new synthetic silk-like fabric to standard cot-ton hospital linens in two groups of patients. The first group involved 307 Medical Renal Unit patients at risk for develop-ing pressure ulcers. The incidence of hospital-acquired pres-sure ulcers was significantly lower (P <0.05) in the interven-tion (4.6%) than in the control group (12.3%). The second group comprised 275 patients in a Surgical Intensive Care Unit (ICU) who were followed for 8 weeks. The incidence of new pressure ulcers was 7.5% in the regular hospital linen (control) and 0% in the silk-like fabric (intervention) group (P = 0.01). The results of this study were encouraging and warranted additional research in other patient populations at risk for pressure ulcer development.

The purpose of this retrospective study was to compare the incidence of hospital-acquired pressure ulcers in pa-tients admitted to Telemetry, Urology, and ICU before and after hospital linens were changed from standard to silk-like linens.

methods and ProceduresA retrospective, before-and-after comparative study was

conducted at the 175-bed Wesley Long Hospital, Greensboro, NC from December 2010 to May 2011. On March 5, 2011, the entire Wesley Long Hospital converted from conventional

cotton-blend linens, underpads, and gowns to the silk-like bed linens, underpads, and patient gowns. This date was used to retrospectively compare the development of pressure ul-cers in Telemetry, Urology, and ICUs (study units) before and after the conversion. As a result of the experiences and results from the prior Surgical ICU study,7 no informed consent was obtained from patients in this study. Investigational Review Board (IRB) approval for the study was obtained from the 17-member Moses Cone Health System IRB.

Available research and statistical calculations suggested the estimated appropriate sample size at 80% power was 174 subjects per group, or a total of 348 patients.8,9

Methodology. The study units were chosen because they were populated by patients at risk for developing pressure ulcers. The study periods for the control and intervention groups were 12 weeks each for a total of 24 weeks. Using convenience sampling methods, all data were collected ret-rospectively from patient medical records during the period December 1, 2010 through February 28, 2011 for the con-trol and March 7, 2011 through May 30, 2011 for the inter-vention group.

Inclusion/exclusion criteria. Data from all patients ad-mitted or transferred to the study units during the study periods qualified for abstraction if their length of stay was 48 hours or more. Data from patients assigned to highly specialized beds that required proprietary coverings, or no bed coverings, by bed manufacturers were excluded from the trial, as were data from patients whose stay on the study units overlapped the conversion date. Patients included in the study data were either on the control or intervention linens for their entire stay in the hospital.

Products. Control linens included a conventional, usu-al-care hospital flat top sheet, fitted bottom sheet, pillow-case, reusable underpad, and patient gown, all made with

Key Points• Theauthorsconductedaretrospectivechart

review of patients admitted to Telemetry, Urology, and Intensive Care Units before and after hospital linens were changed from standard to the synthetic (intervention) linens.

• Onadmissiontotheunits,nosignificantdifferencesin patient demographics or pressure ulcer (PU) preva-lence rate were observed.

• Duringanaveragestayof5days(bothgroups),68of659 patients (10.3%) in the control and 19 out of 768 patients in the intervention group (2.5%) developed one or more PUs (P <0.001).

• Additionalstudiesintotheroleofbedlinensontheincidence of hospital-acquired PUs are warranted.

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cotton-blend fabrics. Intervention linens included a flat top sheet, fitted bottom sheet, pillowcase, reusable underpad, and patient gown, all made with the new synthetic silk-like fab-ric. The intervention underpad was identical to the control underpad with the exception of the top surface fabric (the surface fabric — the layer closest to the patient’s skin — was comprised of the silk-like fabric. The inner “soaker” layer and moisture barrier used in the intervention underpad were the same as used in the control underpad). All under-pads were reusable.

Care protocol. All patients received standard care appro-priate for their medical needs, including positioning, ongoing management for nutritional stability,10 moist wound dress-ings for new or existing ulcers, and incontinence manage-ment. Standard care also included a daily skin assessment by the nursing staff to determine the presence and stage of the pressure ulcer. If a patient was admitted with a pressure ulcer, it was documented and staged per National Pressure Ulcer Advisory Panel (NPUAP) guidelines11 by staff nurses who are educated annually on assessment and staging of pressure ulcers and use of the Braden Scale.12 Data were col-lected for skin issues identified as Stage I through Stage IV pressure ulcers, unstageable ulcers, and deep tissue injury (DTI). Daily skin assessment results were recorded per stan-dard hospital protocols.

Data abstraction. Computerized case report forms were used to collect retrospective information for each pressure ulcer, including the wound stage.

Information from patient records was abstracted and en-tered into a Microsoft Access data collection tool by a study nurse (RN). Information collected included patient demo-graphic data (weight, age, gender, and medical diagnosis), patient comorbidities (hypertension, pulmonary, diabetes, atherosclerosis, neoplasm, heart failure, renal failure, demen-tia, chronic kidney disease, cerebral vascular accident [CVA], myocardial infarction, infectious disease, drugs/alcohol, thrombophlebitis, pain, asthma, osteoporosis, and peripheral vascular disease), albumin level, and Braden Scale total and subscores. If a pressure ulcer was present on admission, that information and the ulcer stage also were abstracted.12 No at-tempt was made to segregate patient data by unit type.

Follow-up variables abstracted included admission and discharge date (number of days in unit), and whether the pa-tient developed a pressure ulcer and ulcer stage.

Data storage. Information that might identify the patient was not included. Two files were used to de-identify patient criteria. The first file included the patient’s medical record number and was linked to the subjects’ study identification number. The Microsoft Excel file, linking patient medical re-cord number and participant study identification number, was maintained in a secure location within the Cone Health System, accessible only to authorized individuals. A second separate file, which involved the Microsoft Access data collec-tion tool, was linked only to participant study identification

number. The second file including only de-identified patient data also was stored in a secure location accessible only to the study’s principal and associate investigators.

Data analysis. The primary endpoint was the incidence rate of hospital-acquired pressure ulcers. Descriptive statis-tics were used to summarize all demographic, comorbidity, and outcome variables, including number of hospital-ac-quired and present-on-admission pressure ulcers. Control and intervention groups were compared using the t-test sta-tistical method assuming equal variances.13 In this study, the unpaired t-test was applied to find the difference between the means of sample variables of the two independent samples. A test of statistical significance was derived and compared with a set of t-distribution tables to see whether the null hy-pothesis should be rejected or not, the probability of which is quantified by the calculation of a P value. Statistical sig-nificance was indicated when P <0.05 — ie, there is a 95% or greater chance the differences in the means, or averages, were not due to chance. Statistical calculations were performed us-ing StatPlus® Professional Software v2009 (AnalystSoft, Inc, Alexandria, VA).

resultsData were abstracted from a total of 1,427 patients, 659

(297 men, 362 women) in the control and 768 (330 men, 438 women) (P = 0.20) in the intervention group. The study was sufficiently sized to detect clinically important differences in endpoints. On admission, with the exception of age, no significant differences in demographic variables (weight, age, and albumin level) between the two groups were observed. The average age of the control and intervention groups was 69.5 (σ = 33.5) and 66.4 (σ = 17.0) years, respectively (P = 0.01) and average weight was 81.1 Kg (σ = 25.3) and 80.4 Kg (σ = 24.5), respectively (P = 0.31). On admission, average albumin levels in the control and intervention groups were 3.02 g/dL (σ = 0.6) and 3.03 g/dL (σ = 0.6), respectively (P = 0.41) (see Table 1).

The majority of patients had several comorbidities, in-cluding hypertension (981, 68.7%), pulmonary disease (534, 37.4%), diabetes (515, 36.1%), neoplasm (406, 28.5%), and atherosclerosis (368, 25.8%), but few significant differences between patients in the control and intervention groups were observed (see Table 2). Atherosclerosis, renal failure, and de-mentia were more common in the control group, whereas hy-pertension and infectious disease were more common in the intervention group. Differences in the overall Braden Scale score and Braden subscales between control and intervention group patients were small (see Table 3) and significantly dif-ferent for the Activity subscale only. The average total Braden scores for the control and intervention groups at admission were 17.3 (σ = 3.0) and 17.1 (σ = 2.9), respectively (P = 0.10) (see Table 3).

On admission, the percentage of patients with pressure ulcers in the control and intervention groups was 9.9% (σ

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= 0.3) and 8.7% (σ = 0.3), respectively (P = 0.23) (see Table 4). A total of 65 control patients were admitted with 90 pres-sure ulcers (9.9%), compared to a total of 67 intervention pa-tients admitted with 80 pressure ulcers (8.7% of patients) (P = 0.23) (see Table 4). During the study, 68 out of 659 patients (10.3%, σ = 0.3) in the control and 19 out of 768 patients in the intervention group (2.5%, σ = 0.2) developed a pressure ulcer (P <0.001) during an average length of stay of 5.56 days (σ = 4.6) for control and 5.21 days (σ = 4.1) for intervention patients (P = 0.08). Thirty-seven patients (37, 5.6%) in the control and 18 patients (2.3%) in the intervention group de-veloped a Stage I pressure ulcer (P <0.001). Thirty-nine (39) patients (5.9%) in the control and six (6) patients (0.8%) in the intervention group developed a Stage II or greater pres-sure ulcer (P < 0.001) for a total incidence of 11.5% in con-trol and 3.1% in the intervention group. The average number of pressure ulcers per patient was 0.137 (σ = 0.5) on admis-sion and 0.206 (σ = 0.6) on discharge in the control group (P = 0.01). The average number of pressure ulcers per patient in the intervention group was 0.106 (σ = 0.4) on admission and 0.083 (σ = 0.3) at discharge (P = 0.11) The average num-ber of new pressure ulcers per patient was 0.134 (σ = 0.4) in the control and 0.025 (σ = 0.2) in the intervention group (P <0.001). At discharge, 13.4% (σ = 0.3) of control and 6.8% (σ = 0.3) of intervention patients (P <0.001) had an ulcer (see Table 4).

No adverse effects or reactions related to the use of the intervention products were reported during the study.

discussionPrior published studies involving patients in acute care

hospitals have determined the overall incidence of pressure ulcers can range from 0.9% to 25.0%. On the low end of the range, in a retrospective study of adult medical-surgical and critical-care patients admitted to a 543-bed facility over a year’s time, including routine quality control reports on patients with facility-acquired pressure ulcers, Jackson14 re-ported an overall pressure ulcer incidence of 368 in 41,840 admissions, or 0.9%. Patients studied by Jackson were, on av-erage, 62 years in age and 60%/40% male/female. All pressure ulcer stages — Stage I through Stage IV, DTI, and unstageable — were considered. On the high end of the range, in an audit study of patients at a community hospital, Oot-Giromini15

table 1. Patient demographic variables on admission

Variable Control group(n=659)

Intervention group (n=768)

P

Mean SD Mean SD

Weight (Kg) 81.1 25.3 80.4 24.5 0.31

Age (years) 69.5 33.5 66.4 17.0 0.01

Albumin level (g/dL)

3.02 0.6 3.03 0.6 0.41

table 3. admission Braden scale scores

Control group(n=659)


P

Mean SD Mean SD

Perception 3.17 0.6 3.22 0.7 0.06

Moisture 3.60 0.6 3.61 0.6 0.42

Activity 2.55 1.0 2.27 1.1 <0.001

Mobility 2.89 0.7 2.92 0.7 0.21

Nutrition 2.75 0.6 2.70 0.7 0.09

Friction 2.38 0.6 2.42 0.6 0.10

Total Braden Scale score

17.32 3.0 17.12 2.9 0.10

table 2. Patient diagnoses and comorbidities

Comorbidity Control group(n=659)


P

n (%) SD n (%) SD

Hyper-tension

467 (70.9%)

0.5 514 (66.9%)

0.5 0.05

Pulmonary 258 (39.1%)

0.5 276 (36.0%)

0.5 0.11

Diabetes 242 (36.7%)

0.5 273 (35.6%)

0.5 0.34

Athero-sclerosis

186 (28.2%)

0.5 182 (23.7%)

0.4 0.03

Neoplasm 179 (27.1%)

0.4 227 (29.6%)

0.5 0.15

Heart failure 160 (24.3%)

0.4 161 (21.0%)

0.4 0.07

Renal failure 107 (16.2%)

0.4 90 (11.7%)

0.3 0.01

Dementia 95 (14.4%)

0.4 85 (11.1%)

0.3 0.03

Chronic kid-ney disease

95 (14.4%)

0.4 109 (14.2%)

0.3 0.45

Cerebral vascular ac-cident (CVA)

89 (13.5%)

0.3 87 (11.3%)

0.3 0.11

Myocardial infarction

67 (10.2%)

0.3 65 (8.5%)

0.3 0.13

Infectious disease

66 (10.0%)

0.3 111 (14.4%)

0.4 0.01

Drugs/alco-hol

60 (9.1%)

0.3 84 (10.9%)

0.3 0.13

Thrombo-phlebitis

58 (8.8%)

0.3 78 (10.2%)

0.3 0.20

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found the incidence of hospital-acquired pressure ulcers for 176 patients was 25%. The demographic in this study includ-ed all units, except maternity, nursery, and ambulatory sur-gery, at all pressure ulcer stages. In the current study, 10.3% of the control group and 2.5% of intervention group patients developed a pressure ulcer during a length of stay of approxi-mately 5 days, well within published ranges.

Control patients in the current study were admitted with 22.8% more pressure ulcers per patients than intervention patients (0.137 [σ = 0.5] versus 0.106 [σ = 0.4], respectively [P = 0.08]). The control group also had a higher incidence of hospital-acquired ulcers than the intervention group. Even though admission Braden Scale scores were not significant-ly different, these findings suggest the control group was at more risk for pressure ulcer development than the interven-tion group.

The medical literature has shown higher rates of pres-sure ulcers in critical care areas of the hospital (ie, telemetry, urology, and ICU), where the incidence of hospital-acquired pressure ulcers can range from 15% to 40%.16,17 In a nested case-control study performed by Baumgarten et al16 at two teaching hospitals involving 792 total cases, 195 patients (24.6% of total cases), including 117 ICU patients (14.8% of total cases and 60% of those patients with pressure ulcers), developed hospital-acquired pressure ulcers. The patient demographic in this study was 40% male/60% female, with

Table 4. Percentage of patients with pressure ulcers (PUs)

Control group

(n = 659)n (%)

Intervention group

(n = 768)n (%)

P

Patients with PUs: all stages

Present on admission

65 (9.9%) 67 (8.7%) 0.23

Acquired during stay

68 (10.3%) 19 (2.5%) <0.001

At discharge 88 (13.4%) 52 (6.8%) <0.001

Patients with Stage I PUs


40 (6.1%) 40 (5.2%) 0.24


37 (5.6%) 18 (2.3%) <0.001

At discharge 47 (7.1%) 40 (5.2%) 0.07

Patients with Stage II+ PUs


33 (5.0%) 30 (3.4%) 0.16


39 (5.9%) 6 (0.8%) <0.001

At discharge 47 (7.2%) 14 (1.8%) <0.001

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participant age ≥65 years. One of Baumgarten et al’s key find-ings was the odds of developing a pressure ulcer were twice as high for patients with an ICU stay than those without.

Incidence rates in specific medical units were surveyed in a cross-sectional cohort study assessing pressure ulcer preva-lence18; 92,408 US patients were surveyed in all care settings. Of those surveyed, 94% were in acute care, 2.3% in long-term care, 1.7% in rehab facilities, 1.6% in long-term acute care, and 0.3% in home care. The International Pressure Ulcer Prevalence Survey (IPUP)17 found the prevalence of facility-acquired pressure ulcers was 5.1% for telemetry units (cardi-ac, general, medical, surgical, n = 718), 5.1% for urology units (n = 46), and 10.1% for ICUs (surgical, general, medical, n = 873). In the current study involving patients from telemetry, urology, and ICUs, 10.3% of control and 2.5% of interven-tion patients developed pressure ulcers, with an incidence of 11.5% in control and 3.1% in the intervention group. Con-trol patients in this study developed pressure ulcers at a rate similar to ICU patients in the IPUP survey; however, the in-tervention group incidence rate for facility-acquired pressure ulcers was well below any of the critical care units reported by IPUP.

The results of this study are similar to those reported ear-lier comparing regular bed linens to a silk-like fabric,7 sug-gesting that bed linens, underpads, and patient gowns may affect the incidence of hospital-acquired pressure ulcers. Pro-spective, controlled, clinical studies of bed linens and patients in other high risk patient populations such neonatal and pe-diatric intensive care units, burn units, and long-term acute-care facilities,18 are warranted.

LimitationsRetrospective before-and-after study design limitations

inherently include potential missing, incomplete, or inaccu-rate data.

Existing pressure ulcers at admittance could have been an indicator of further ulcer development. However, the over-all levels of pressure ulcer development for homogeneous groups of patients were analyzed to produce statistically sig-nificant differences.

Patients assigned to highly specialized beds that required proprietary coverings or no coverings by bed manufacturers, rather than standard cotton-blend bed linens, were excluded from the study, which probably lowered the actual overall in-cidence rate in both arms of the study.

ConclusionIn this retrospective, nonrandomized, before-and-after

controlled study involving 1,427 patients, the incidence of patients with facility-acquired pressure ulcers at all stages

was 10.3% for the control group compared to 2.5% for the intervention group (P <0.001). The incidence of Stage I pres-sure ulcers was 5.6% in the control group compared to 2.3% in the intervention group (P <0.001), and 5.9% in the control and 0.8% in the intervention group for ulcers Stage II and greater (P <0.001). The total incidence of facility-acquired pressure ulcers was 11.5% in the control and 3.1% in the in-tervention group. Prospective, controlled clinical studies are needed to further elucidate the impact of a synthetic silk-like technology on persons at high risk for the development of pressure ulcers and skin breakdown. n

references 1. Zhong W, Ahmad A, Xing MM, Yamada P, Hamel C. Impact of textiles on

formation and prevention of skin lesions and bedsores. Cutaneous Ocular Toxicol. 2008;27(1):21–28.

2. Biesecker JE, Thomas HL, Thacker JG, Blackwood HS, Edlich RF. Innova-tions in the design and performance of underpads for patients with burns. J Burn Care Rehab. 1995;16(1):66–73.

3. Pryczynska E, Lipp-Symonowicz B, Wieczorek A, Gaszynski W, Krekora K, Bittner-Czapinska E. Sheet fabrics with biophysical properties as elements of joint prevention in connection with first- and second-generation pneumatic anti-bedsore mattresses. Fibers Textiles Eastern Eur. 2003;4(43):50–53.

4. Gray M, Black JM, Baharestani MM, Bliss DZ, Colwell JC, Goldberg M, et al. Moisture-associated skin damage — overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233–241.

5. Gerhardt LC, Mattle N, Schrade GU, Spencer ND, Derler S. Study of skin-fabric interactions of relevance to decubitus: friction and contact-pressure measurements. Skin Res Technol. 2008;14(1):77–88.

6. Internal testing of healthcare cotton-blend fabrics by Precision Fabrics Group, Inc, January — June 2011.

7. Coladonato J, Smith A, Watson N, Brown AT, McNichol LL, Clegg A, et al. Prospective, nonrandomized controlled trials to compare the effect of a silk-like fabric to standard hospital linens on the rate of hospital-acquired pressure ulcers. Ostomy Wound Manage. 2012;58(10):14–31.

8. Montgomery DC. Design and Analysis of Experiments, 5th ed. New York, NY: John Wiley & Sons, Inc;2001.

9. Zar JH. Biostatistical Analysis, 4th ed. Singapore: Pearson Education, Inc;2009.

10. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Available at: www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf. Accessed February 4, 2013.

11. National Pressure Advisory Panel. Pressure Ulcer Category/Staging Il-lustrations. Available at: www.npuap.org/pr2.htm. Accessed February 15, 2012.

12. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for pre-dicting pressure sore risk. Nurs Res. 1987;36(4):205–210.

13. Lowry R. Concepts and Applications of Inferential Statistics. t-Test for the Significance of the Difference between the Means of Two Indepen-dent Samples.1999–2013. Available at: www.vassarstats.net/textbook/ch11pt1.html. Accessed February 10, 2012.

14. Jackson SS. Incidence of hospital-acquired pressure ulcers in acute care using two different risk assessment scales: results of a retrospective study. Ostomy Wound Manage. 2011;57(5):20–27.

15. Oot-Giromini B, Bidwell FC, Heller NB, Parks ML, Wicks P, Williams PM. Evaluation of skin care: pressure ulcer prevalence rates pre/post interven-tion. Decubitus. 1989;2(2)54–55.

16. Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kino-sian B, et al. Extrinsic risk factors for pressure ulcers early in the hos-pital stay: a nested case-controlled study. J Gerontol A Biol Sci Med. 2008;63(4):4008–4013.

17. VanGilder C, Amlung S, Harrison, P, Meyer S. Results of the 2008–2009 International Pressure Ulcer Prevalence™ Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage. 2009; 55(11):39–45. DO N

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