Heel Ulcer Incidence Following Orthopedic Surgery: A Prospective, Observational Study
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Study findings support results of previously published reports5,7 that HPUs in orthopedic patients occur in the acute care facility. Results also suggest that prevention efforts should focus on acute care facilities and that current efforts to prevent these ulcers in the community and rehabilitation facilities are effective.
Incidence estimates. The cumulative HPU incidence in this orthopedic patient population was 17% (95% CI 8%–26%). This estimate for HPUs is similar to, but slightly higher than, results from the authors’ previous study15 conducted among orthopedic patients (HPUs incidence of 13.3%, (95% CI to be 8%–18%) but within the confidence interval.
The current estimate of HPUs incidence in the orthopedic population is higher than the 0% to 9.1% previously reported by Frain et al,28 who used a prospective design to examine HPUs occurrence in orthopedic patients in a US long-term care facility (n = 40).
In the current study, the HPUs incidence estimate in this specific orthopedic population is similar to previous reports of HPUs incidence occurring in a general acute care population. In a retrospective chart audit29 reviewing skin surveys of all patients admitted to medicine or surgery in an acute care facility (N= 237), the cumulative HPUs incidence was found to be 13.5%. A prospective study by Tourtual et al30 estimated the cumulative incidence of HPUs in a US acute care facility was higher (26.8%), but this study included only patients from four care units (n = 291) that had the highest prevalence of PU, and selecting high-risk care units may account for the relatively high HPUs incidence reported.
The current study did not identify any new heel ulcers in these patients while they were in rehabilitation or at home. Prospective studies8-10 have reported an incidence of 0% in all PU in rehabilitation facilities, and retrospective chart reviews11,12 have estimated the incidence of all PU in rehabilitation settings to be 6%. The results of the current study are also consistent with a prospective study9 that estimated a 0% cumulative PU incidence in any anatomical location in community-dwelling patients. These findings are lower than the estimated cumulative incidence of 3.2% reported in the results of a retrospective study31 (n = 1,711) that examined the overall cumulative incidence of PU in the community with patients receiving home care.
Impact of data collection methods. Data collection methods seem to be an important determinant in estimating PU incidence. Prospectively determined cumulative incidence estimates are reported to be 8.8% to 19.1% lower than those of researchers using retrospective chart reviews8,9 to examine PU in the hip fracture population. Research in Sweden32 that compared a retrospective chart audit to a prospective study using direct physical exam of patients in surgical, orthopedic, medical, and geriatric departments found a 14.3% PU prevalence using retrospective chart audit and a 33.3% prevalence when patients were examined prospectively. These results suggest that PU incidence estimates using a retrospective approach that relies on accurate PU charting may not provide an accurate estimate of the extent of the problem.
To further confound this area of research, one must be aware of how the incidence value is reported. Although incidence is consistently defined as “the proportion of a group initially free of the condition that develops the condition over a period of time,”32 the manner by which it is estimated can vary.