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More on Pressure Ulcers in Long-Term Care

Zulkowski, Karen DNS, RN, CWS

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Advances in Skin & Wound Care: June 2004 - Volume 17 - Issue 5 - p 216

To the editor:

I enjoyed reading the article,“Pressure Ulcers and the Transition to Long-Term Care,”by Baumgarten et al 1 in the November 2003 issue of Advances in Skin & Wound Care. The work described in this paper is similar to my work with the MDS+ items and residents newly admitted to a long-term-care facility. 2–5

Because I still had my original data set, I decided to re-examine it and see how it corresponded with the results presented by Baumgarten et al. I found many similarities. My study published in 1998 2 included 990 subjects newly admitted to nursing homes in western New York. The mean age of those admitted from the hospital was 84 years (SD=7) in my study and 81 years (SD=7.7) in Baumgarten et al. Of the individuals admitted from the hospital with pressure ulcers, 11% were incontinent of bladder, 4% of bowel, and 21.5% of both (14.3%, 9.9%, and 29.5%, respectively, in Baumgarten et al).

I included Stage I pressure ulcers in the analysis (Baumgarten et al did not) because medical record/MDS documentation is often incorrect and I did not use direct patient observation. In the total sample, the pressure ulcer prevalence was 33% (n=329); it was 10.3% in Baumgarten et al. For individuals admitted to the nursing home from a hospital, the pressure ulcer prevalence rate was 36% (n=293) in my study and 11.9% in Baumgarten et al. In other words, 89% (n=293) of individuals admitted to the nursing home from the hospital in my study had a pressure ulcer. This is a significant number, and perhaps my study should have included it in regression analysis as a possible predictor of prevalence.

In 1998, one did not need patient permission to review medical records, so all newly admitted patients were included in my data set. The inclusion of all subjects and subsequent improvement in preventive care may have contributed to my study’s higher prevalence rate.

I also examined nutritional status in my research, and I found that the lower the serum albumin level, the higher the pressure ulcer risk. Individuals with pressure ulcers had an albumin of 3.06 gm/dL, compared with 3.3 gm/dL for those that did not have pressure ulcers.

Although the albumin level was below normal for the entire sample, it was higher than I found in later nutritional research with individuals newly admitted to an acute care hospital. 6 In fact, individuals newly admitted to a hospital had an albumin level of 3.0 gm/dL regardless of whether a pressure ulcer was present. Consequently, it is not surprising that individuals admitted to a nursing home from a hospital had a higher prevalence rate than those admitted from other care settings.

I would like to second the statement in Baumgarten et al that the time of transition from one health care setting to another “represents a period of vulnerability for elderly patients.” 1 This is an important point for health care providers to consider. Patients admitted to an acute care setting generally have no nutritional reserves; any they might have had are quickly depleted by an exacerbation of disease or the condition that necessitated hospitalization.

I commend the work by Baumgarten et al and hope research such as this will continue to highlight the frequently overlooked need for prompt nutritional intervention and better risk management in the acute care setting.

Karen Zulkowski DNS, RN


1. Baumgarten M, Margolis D, Gruber-Baldini AL, et al. Pressure ulcers and the transition to long-term care. Adv Skin Wound Care 2003;16:299–304.
2. Zulkowski K. MDS+ RAP items associated with pressure ulcer prevalence in newly institutionalized elderly: study I. Ostomy Wound Manage 1998;44(11):40–4, 46–8, 50, passim.
3. Zulkowski K. A conceptual model of pressure ulcer prevalence: MDS+ items and nutrition. Ostomy Wound Manage 1999;45:36–44.
4. Zulkowski K. MDS+ items not contained in the pressure ulcer RAP associated with pressure ulcer prevalence in newly institutionalized elderly. Ostomy Wound Manage 1999;45(1):24–33.
5. Zulkowski K. A conceptual model of pressure ulcer prevalence: MDS+ items and nutrition. Ostomy Wound Manage 1999;45(2):36–8, 40, 42–4.
6. Zulkowski K, Kindsfater D. Examination of care-planning needs for elderly newly admitted to an acute care setting. Ostomy Wound Manage 2000;46(1):32–8.


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