Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?

Can a prolonged healing pressure injury be benefited by using an AI mattress? A case study

BACKGROUND

Pressure injuries are a common and serious issue for bedridden residents in long-term-care facilities. Areas of bony prominences, such as the scapula, sacrum, and heels, are more likely to develop pressure injuries. The management of pressure injury wounds include dressing changes, repositioning, away from moisture, decreasing the occurrence of friction and shear, and more. Some supportive surfaces are also used for pressure injury cases such as gel pads, alternating pressure air mattresses, and air-fluidized beds. The aim of this case study was to determine whether the use of an artificial intelligent mattress can improve a nursing home resident with prolonged pressure injury.

CASE PRESENTATION

A retrospective study design was conducted for this case study. A 79-year-old male developed a pressure injury in the sacrum. His pressure injury was initially at stage 4, with a score of 12 by the Braden scale. The PUSH score was 16. During 5.5 months of routine care plus the use of the traditional alternative air mattress, in the nursing home, the wound stayed in stage 3 but the PUSH score increased up to 11. An artificial intelligence mattress utilizing 3D InterSoft was used to detect the bony prominences and redistribute the external pressure of the skin. It implements a color guided schematic of 26 colors to indicate the amount of pressure of the skin.

RESULTS

The wound size was decreased and all eczema on the resident's back diminished. The PUSH score was down to 6, as the artificial intelligent mattress was added into the routine care. The staff also reported that the resident's quality of sleep improved and moaning decreased. The hemiplegic side is at greater risk of developing pressure injury.

CONCLUSIONS

This novice device appeared to accelerate wound healing in this case. In the future, more cases should be tested, and different care models or mattress can be explored.

The clinical applicability of sensor technology with body position detection to combat pressure ulcers in bedridden patients

INTRODUCTION

Pressure Ulcers (PUs) are a major healthcare issue leading to prolonged hospital stays and decreased quality of life. Monitoring body position changes using sensors could reduce workload, improve turn compliance and decrease PU incidence.

METHOD

This systematic review assessed the clinical applicability of different sensor types capable of in-bed body position detection.

RESULTS

We included 39 articles. Inertial sensors were most commonly used (n = 14). This sensor type has high accuracy and is equipped with a 2-4 hour turn-interval warning system increasing turn compliance. The second-largest group were piezoresistive (pressure) sensors (n = 12), followed by load sensors (n = 4), piezoelectric sensors (n = 3), radio wave-based sensors (n = 3) and capacitive sensors (n = 3). All sensor types except inertial sensors showed a large variety in the type and number of detected body positions. However, clinically relevant position changes such as trunk rotation and head of bed elevation were not detected or tested.

CONCLUSION

Inertial sensors are the benchmark sensor type regarding accuracy and clinical applicability but these sensors have direct patient contact and (re)applying the sensors requires the effort of a nurse. Other sensor types without these disadvantages should be further investigated and developed. We propose the Pressure Ulcer Position System (PUPS) guideline to facilitate this.

Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BACKGROUND

Subepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.

AIM

The primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.

METHODS

Healthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.

RESULTS

A total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.

CONCLUSION

In a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.

Preventive effect of cluster nursing on pressure ulcers in orthopedic patients and predictive value of serum IL-6 and TNF-α for the occurrence of pressure ulcers

OBJECTIVE

To determine the effect of cluster nursing on pressure ulcer prevention and comfort of orthopedic patients.

METHODS

A total of 124 orthopedic inpatients admitted to the Seventh Affiliated Hospital of Sun Yat-sen University from July 2018 to June 2021 were retrospectively analyzed. Among them, 66 cases received cluster nursing who were assigned into the observation group and the other 58 cases received routine nursing and were assigned into the control group. The incidence of pressure ulcers, the degree of pressure the ulcer, quality of life-brief (QOL-BREF), self-rating anxiety scale (SAS), and self-rating depression scale (SDS) scores of the two groups at 7 days after surgery were compared, and the comfort score and nursing satisfaction of the two groups were evaluated and compared. The expression and predictive value of serum interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in patients with pressure ulcers before operation were analyzed via enzyme-linked immunosorbent assay (ELISA). The levels of IL-6 and TNF-α were compared between the two groups before and after nursing.

RESULTS

After nursing, the observation group had significantly lower IL-6, TNF-α, SAS score, and SDS scores than the control group, and showed significantly higher QOL-BREF score, nursing satisfaction and comfort scores than the control group. In addition, the observation group showed a significantly lower incidence of pressure ulcers and a significantly lower severity level than the control group after nursing. Patients with pressure ulcers showed significantly higher serum IL-6 and TNF-α levels before surgery, and receiver operating characteristic curve (ROC) showed that IL-6 and TNF-α had certain value in forecasting the occurrence of pressure ulcers.

CONCLUSION

Cluster nursing can substantially lower the incidence of pressure ulcers in hospitalized orthopedic patients and improve their comfort.

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results

OBJECTIVE

To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks.

METHODS

An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity.

RESULTS

From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P < .001).

CONCLUSIONS

Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

To Turn or Not to Turn: Exploring Nurses' Decision-Making Processes Concerning Regular Turning of Nursing Home Residents

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD (n = 62, 70%) and non-ADRD (n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

Battery-free, wireless soft sensors for continuous multi-site measurements of pressure and temperature from patients at risk for pressure injuries

Capabilities for continuous monitoring of pressures and temperatures at critical skin interfaces can help to guide care strategies that minimize the potential for pressure injuries in hospitalized patients or in individuals confined to the bed. This paper introduces a soft, skin-mountable class of sensor system for this purpose. The design includes a pressure-responsive element based on membrane deflection and a battery-free, wireless mode of operation capable of multi-site measurements at strategic locations across the body. Such devices yield continuous, simultaneous readings of pressure and temperature in a sequential readout scheme from a pair of primary antennas mounted under the bedding and connected to a wireless reader and a multiplexer located at the bedside. Experimental evaluation of the sensor and the complete system includes benchtop measurements and numerical simulations of the key features. Clinical trials involving two hemiplegic patients and a tetraplegic patient demonstrate the feasibility, functionality and long-term stability of this technology in operating hospital settings.

A Blanket Accommodative Sleep Posture Classification System Using an Infrared Depth Camera: A Deep Learning Approach with Synthetic Augmentation of Blanket Conditions

Surveillance of sleeping posture is essential for bed-ridden patients or individuals at-risk of falling out of bed. Existing sleep posture monitoring and classification systems may not be able to accommodate the covering of a blanket, which represents a barrier to conducting pragmatic studies. The objective of this study was to develop an unobtrusive sleep posture classification that could accommodate the use of a blanket. The system uses an infrared depth camera for data acquisition and a convolutional neural network to classify sleeping postures. We recruited 66 participants (40 men and 26 women) to perform seven major sleeping postures (supine, prone (head left and right), log (left and right) and fetal (left and right)) under four blanket conditions (thick, medium, thin, and no blanket). Data augmentation was conducted by affine transformation and data fusion, generating additional blanket conditions with the original dataset. Coarse-grained (four-posture) and fine-grained (seven-posture) classifiers were trained using two fully connected network layers. For the coarse classification, the log and fetal postures were merged into a side-lying class and the prone class (head left and right) was pooled. The results show a drop of overall F1-score by 8.2% when switching to the fine-grained classifier. In addition, compared to no blanket, a thick blanket reduced the overall F1-scores by 3.5% and 8.9% for the coarse- and fine-grained classifiers, respectively; meanwhile, the lowest performance was seen in classifying the log (right) posture under a thick blanket, with an F1-score of 72.0%. In conclusion, we developed a system that can classify seven types of common sleeping postures under blankets and achieved an F1-score of 88.9%.

Using the 'aSSKINg' model in pressure ulcer prevention and care planning

Pressure ulcers are painful, costly and can negatively affect a patient's quality of life. It has long been recognised that they increase the risk of infection, prolong hospital stays and can result in death. To prevent the occurrence of pressure ulcers, nurses need to understand what a pressure ulcer is and the underlying factors that cause them. Furthermore, it is essential that they recognise why some people are more susceptible to pressure and shear forces than others, so that preventable factors can be addressed. Nursing care to prevent pressure ulcers needs to be planned, implemented and evaluated in a systematic manner following an assessment of the patient and their circumstances. The 'aSSKINg' (assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help) model ensures all fundamental aspects of pressure ulcer prevention are included in patient care. This article outlines the definitions and causes of pressure ulcers, and explains how nurses can assess, plan, implement and evaluate pressure ulcer preventative care using the aSSKINg model as a guide.

Preventing Pressure Injuries in Nursing Home Residents Using a Low-Profile Alternating Pressure Overlay: A Point-of-Care Trial

BACKGROUND

Pressure injuries (PIs) are a significant concern for patients with very limited mobility in skilled nursing facilities. Conflicting clinical guidelines and a lack of effectiveness data for the various support surfaces reduces the efficacy of PI prevention programs.

OBJECTIVE

To assess the preventive effectiveness (incidence of facility-acquired PIs) of a low-profile alternating pressure (AP) support surface plus facility-specific PI prevention programs in patients at high risk for PI.

DESIGN AND SETTING

Prospective, multicenter, point-of-care observational study in two for-profit nursing homes in the northeastern US.

PATIENTS AND INTERVENTION

A retrospective review of 101 residents was performed to determine baseline PI incidence. Then, a consecutive sample of 25 participants was selected based on the following eligibility criteria: high risk for PI, bedbound (20 hours or more per day), and stay in a mechanical ventilation unit for more than 5 days. The participants were placed on an AP overlay positioned above a facility-provided nonpowered reactive support surface.

MAIN OUTCOME MEASURE

The development of any new PI (stage 1-4), deep-tissue injury, or unstageable PI in participants using the AP overlay. The PI incidence for the AP group was compared with the retrospective baseline PI incidence from the same units in the two nursing homes.

MAIN RESULTS

The group using the AP overlay had a significantly lower PI incidence (0/25, 0%) compared with baseline (22/101, 21.8%; P < .001). Almost 80% of the study participants in the AP group were completely immobile, 100% of the participants were bowel- and bladder-incontinent, their average time on the AP overlay was 140.9 ± 94.1 days, and average length of stay in the facility was 633.9 ± 1,129.1 days.

CONCLUSIONS

The low-profile AP overlay was significantly more effective than facility-specific prevention programs alone in preventing PIs in a high-risk nursing home population over an extended period.

Hospital-acquired pressure ulcer incident rates among hospitals that implement an education program for staff, patients, and family caregivers inclusive of an after discharge follow-up program in Saudi Arabia

A tertiary public hospital in Saudi Arabia set out in 2015 to establish a team focused on reducing hospital-acquired pressure ulcers (HAPUs). The pressure ulcer prevention program (PUPP) had a multifaceted approach and data were collected for a period of 5 years. The results showed a definite reduction in the incidences of HAPUs. Many such programs show similar positive results and echo many of the same considerations of risk, prevention strategies, and the need for early intervention. However, none of the other studies either replicate the hospital's PUPP nor the extent of the positive and lasting effect of the program. Eager to determine the contributing factor(s) in order that the project success could be continued and possibly replicated in other quality improvement projects, it was decided that an examination and comparison of other similar programs and their results would be necessary in order to uncover the answer. It was determined that the in-person in-home discharge follow-up portion of the program most likely had the largest effect on the outcomes. Outcomes that were supported by the pre-work completed during the hospital portion of the PUPP towards reducing HAPUs and readmissions.

Pressure ulcers: the core, care and cure approach

Pressure ulcer/injury remains a significant health problem in the community, requiring comprehensive care. Nurses are involved in the management and prevention of pressure injury. However, to date, studies focusing on applying nursing theory to pressure ulcer care have been limited. In the present study, the three dimensions of Lydia Hall's 1964 theory-core, care and cure-are extensively discussed and linked with the practice of pressure injury management. It is hoped that this review will help community nurses understand the application of this nursing theory to the prevention and management of pressure injury.