The primary care provider for a patient with a pressure ulcer (PrU) in the hospital, nursing home, or at home may be an internist, family medicine physician, or surgeon. Specialists from physical medicine and rehabilitation, plastic surgery, and orthopedic surgery may provide consultative care. Nurses, physical therapists, and dietitians are essential to designing and implementing the overall care plan. 1–5 Yet, the contribution of diverse health care providers is often unrecognized; PrUs are assumed to be a nursing problem, 6 evidenced by the many surveys of nursing knowledge and reports of educational initiatives. 7–12 In comparison, physicians’ knowledge and practice have rarely been studied, 5,13 despite the fact that physicians are ultimately responsible for treating the complications of PrUs. 14,15
Pressure ulcers have recently been chosen as a target condition for quality improvement in geriatric care 16 and identified as a core subject appropriate for undergraduate and graduate medical education. 17–19 Geriatricians are logical clinical leaders and teachers of this subject, which involves an interdisciplinary approach to care 1,4,20; attention to functional status, 21,22 nutrition, 23–25 incontinence, 22,23 and pain management 26; and knowledge of wound management. 27 The American Council for Graduate Medical Education’s accreditation requirements for a geriatrics fellowship include specific content education on PrUs and the “opportunity to teach personnel such as nurses, allied health personnel, medical students, and residents.”28
The objectives of this study were (1) to assess the types of educational exposures that geriatric fellows have during training, and (2) to begin validation of an instrument that examines knowledge of PrU care.
A prospective survey instrument was developed to collect information on educational experiences, self-reported feelings of preparation to manage patients with PrUs and teach about the subject, and content knowledge about PrU care during a geriatrics fellowship. Educational experiences were assessed using an all-that-apply format from a list of choices. Self-reported feelings of preparation were assessed using a 5-point Likert scale. The response choices were labeled (1) none or very little, (3) adequate, and (5) very or a lot.
The knowledge test, modeled after an instrument validated for nurses, 29 was updated with questions based on randomized controlled trials and guidelines on PrU assessment and treatment from the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality). 1,27,30,31 To improve testing characteristics, 5 answer choices were provided instead of 4. The final version of the instrument was composed of 15 questions from the following topic areas: risk factor assessment, primary prevention, PrU staging, topical treatment, nutritional supplements, pressure-modified support surfaces, and complications. The survey was administered to geriatric educators with extensive experience teaching medical students about PrUs to determine content validity. The level of question difficulty was chosen to reflect knowledge that an attending physician specializing in geriatrics would need to teach residents on an inpatient unit. The knowledge instrument was pilot-tested for clarity on 5 third-year medical residents committed to geriatrics fellowships for the following year.
In November 1999, a letter of introduction was faxed to program directors of geriatrics fellowships in New York State. The letter requested the participation of their fellows and assistance with distributing and returning the survey. They were told that the responses of individual fellows would be anonymous and could be traced only to a given training program. The survey instrument was then mailed to these institutions. Institutional review board approval was not sought because the participants could not be identified and the goal of the study was primarily about education.
Twelve of 17 program directors, training a total of 52 fellows, agreed to distribute the survey. The survey was returned by 42 fellows (response rate, 81%) who represented 10 programs, each training from 1 to 12 fellows. Their residency training was in internal medicine (39, 93%) and family medicine (3, 7%). Three had additional residency training in emergency medicine, and 3 others had residency training in surgery.
Participants reported receiving their education about PrUs in one or more of the following clinical practice settings: nursing home (36, 86%), hospital unit (27, 64%), rehabilitation unit (24, 57%), home care (17, 40%), and clinic (16, 38%). Reported sources of information and expert opinion were from one or more of the following: bedside rounds (33, 79%), consultation with nurses (30, 71%), lectures (28, 67%), textbooks (28, 67%), national practice guidelines (26, 62%), consultation with geriatric attendings (25, 60%), medical journals (21, 50%), and consultation with surgeons (21, 50%). No participant used the Internet as an educational resource.
Twenty-nine (69%) of the fellows reported that they had teaching responsibilities on the subject of PrUs. Of these, 26 (90%) taught medical students and residents. Twelve fellows (41%) stated that they taught nurses, and 4 (14%) taught physician assistants.
Self-reported feelings of preparation
The 5 questions on preparation to manage PrUs and teach other clinicians and the mean scaled responses are presented in Table 1. The mean rank for all questions was “adequate,” with the exception of “How prepared do you feel to treat patients with PrUs after fellowship?” Only the question on the amount of practical experience showed a statistically significant positive correlation with the scores on the knowledge test. (Spearman rank correlation R = 0.48, P = .0013).
The mean score and standard deviation (SD) on the knowledge test for the cohort was 58% ± 18% correct. The scores for the individual fellows ranged from 20% to 80% correct, and the fellowship program means ranged from 36% to 62% correct.
Twenty (48%) of the fellows were able to correctly identify the Braden Scale for Predicting Pressure Sore Risk 21 as a risk factor screening instrument (Table 2). Thirty-six (86%) correctly identified immobility as the greatest risk factor for developing a PrU. For questions regarding primary prevention, 28 (67%) of the fellows knew that, even with orders to reposition patients, there is still a role for pressure-modified support surfaces. 27,30
Two questions regarding PrU staging were asked. The following was correctly identified as a Stage I PrU by 28 (67%) of the fellows: “a 2x2 centimeter warm, indurated, discolored area on the sacrum of an African American patient.” Twenty-two (52%) correctly labeled the following as a Stage IV PrU: “a 5x6 centimeter ulcer over the sacrum with a depth of 1 centimeter. The edge is circular with no undermining. There is muscle involvement, and the base is clean with pink granulation tissue.”
For PrU treatment, 18 (43%) of the fellows were consistent with practice guidelines and would use a disposable incontinent brief for incontinent patients. 27,30 Forty (95%) of the fellows identified normal saline as the best solution for routine wound cleansing 31,32 when offered this among choices of diluted iodine surgical scrub, hydrogen peroxide, diluted Ivory soap, or Dakin’s solution. For a topical dressing for a Stage IV PrU, 22 (52%) of the fellows chose moist saline gauze as the most appropriate initial treatment from choices of wet-to-dry gauze with normal saline, wet-to-dry gauze with Dakin’s solution, collagenase with a dry dressing, or application of a recombinant platelet-derived growth factor. Twenty (48%) of the fellows correctly knew that supplemental ascorbic acid twice a day has been shown to be ineffective in accelerating the healing of a PrU. 33 The question with the lowest score was the use of adjuvant electrotherapy for a Stage III or IV PrU unresponsive to conventional treatment. 34–38 Nine (21%) of the fellows answered correctly that this treatment is included in the AHCPR guidelines 27 and is reimbursed by Medicare. 39–41
Regarding the clinical utility of wound cultures, 24 (57%) correctly answered that wound cultures are not useful 42,43; 8 (19%) thought cultures are clinically useful for wounds with surrounding cellulitis. Twenty-two (52%) were unaware that amyloidosis, meningitis, or squamous cell carcinoma are reported complications of PrUs. 44,45
Despite broad exposure to patients with PrUs in many clinical settings and opportunities for interchange with nurses and surgeons, this group of geriatric fellows felt only “adequately” prepared to lead and teach an interdisciplinary team about PrUs. The mean score for the cohort on the knowledge test was below 70%, suggesting that content knowledge of this cohort is below what an attending physician specializing in geriatrics would need in order to teach residents on an inpatient unit.
For this cohort, the learning experience took place at the bedside, which is appropriate for a condition that requires hands-on assessment and allows for participation of nurses and physical therapists. The fellows were exposed to expert opinion from many disciplines, including nurses and surgeons, which is also appropriate. This, plus the fact that many of the fellows had an opportunity to teach medical students and nurses, fulfills the accreditation requirements for a geriatrics fellowship 28 and prepares the fellows for future teaching activities. 46 Although the quality of the Internet as an educational resource is in question, 47 reputable organizations dedicated to wound management have information readily available on the Internet, 39,48–50 none of which was utilized by these geriatric fellows. No explanation was given for this; perhaps it may have been due to lack of awareness of these resources.
The fellows reported that they had “adequate” preparation for and confidence in selecting wound care products, directing nurses and other health care providers, and teaching. Being prepared to treat patients with PrUs rated the highest response on the Likert scale. This may have been the result of the wording of the question, reflecting the fellows’ comfort in providing overall geriatric care to a patient who has a PrU as one of his or her many medical problems.
Most of the survey participants recognized risk factors for the development of PrUs, but fewer recognized the Braden Scale, a validated and widely used risk-screening tool. 21 Although many of the fellows knew basic PrU staging and treatment, a surprising number were unaware of the lack of clinical utility of wound cultures and vitamin C supplements. This is a significant deficit of knowledge, considering that geriatricians see patients with PrUs in nursing homes and hospitals every day. The wide range of scores also suggests the lack of a consistent curriculum for PrUs during fellowship.
This pilot study has several limitations. The results should be considered exploratory, pending a geographically larger survey of fellows and recent graduates. Fellows in a single state were surveyed in this pilot study; these findings may not be applicable to geriatrics fellowship training in general. The survey did not ask participants if they were in their first or second year of fellowship; therefore, it cannot be determined what level of experience and training the participants had regarding the care and treatment of PrUs.
The instrument used in this pilot study to assess the fellows’ knowledge has not yet been validated; therefore, it is not included in this report. However, much of the content of the questions from the test and literature sources for the correct answers are provided. In addition, the instrument was mailed to participants and was administered in a nonstandard testing situation with potential for open book and group test taking. Based on the scores, however, it is doubtful that this occurred.
When evaluating the findings, sample bias must be taken into consideration. Only 12 of 17 programs responded and, of these 12 programs, only 42 of 52 fellows returned the survey. It is possible that those programs or participants with the least interest or knowledge regarding PrUs were less likely to respond. Therefore, the results may be biased toward a higher estimate of knowledge.
It has been suggested that an insufficient number of geriatricians are being trained to care for the increasing number of older patients who have unique medical needs. 51–53 This study on a single educational topic suggests that we also may not be training an acceptable quality of geriatrician. Even geriatricians in purely clinical roles will be asked to consult and teach colleagues about PrUs and should have confidence in team leadership for PrU care.
In summary, this small cohort of geriatric fellows in New York State were taught about PrUs in an appropriate educational format (at the bedside) and had opportunities to work with other disciplines and medical specialties. However, they have a considerable need to improve their knowledge and, therefore, confidence to become expert clinicians and educators on the subject of PrUs. Development of specific curricular guidelines for the subject of PrUs and a validated knowledge assessment instrument will allow improved standardization of curricula and ability to measure the educational effectiveness of geriatrics fellowship training.
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