Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors

Risk factors for oral mucosal pressure injury associated with endotracheal tubes in intensive care unit patients: A single-centre longitudinal study with brief follow-up

BACKGROUND

In intensive care units (ICUs), endotracheal tubes (ETTs) cause injury to the oral mucosa through friction and pressure. The incidence and risk factors of oral mucosal pressure injuries (PIs) have gained increasing attention in recent years.

AIM

The study aimed to identify risk factors for oral mucosal PIs associated with ETTs.

STUDY DESIGN

This was a single-centre brief follow-up longitudinal study conducted from January to May 2022. It recruited 250 patients without oral mucosal PIs who received mechanical ventilation support via ETT and were hospitalized in the ICU of a teaching and research hospital in Turkey. Receiver operating characteristic (ROC) analysis was performed to estimate the onset time of oral mucosal PI using the ETT repositioning time as an independent variable.

RESULTS

Oral mucosal PIs associated with ETT developed in 41.6% of patients. Of the 250 endotracheally intubated patients, the mean Acute Physiology and Chronic Health Evaluation (APACHE-II) score was 27.5 (min/max: 18/42), the mean length of stay (LOS) in the ICU was 24 days (min/max: 13/80). The median body mass index (BMI) of patients with oral mucosal PIs was (24.59 [IQR = 3.81] kg/m2), significantly lower than the median BMI of patients without oral mucosal PIs (26.62 [IQR = 5.93] kg/m2) (Z = 4.200; p < .001). The earliest onset of oral mucosal PIs was noted at 16 h after the start of follow-up, and the latest was 208 h after the start of follow-up, with a median of 160 (IQR = 48) h (approximately 6.7 days). Patients whose ETT was repositioned after 10.5 h had a higher risk of developing oral mucosal PIs (OR = 3.77; 95% CI: 2.65-5.37; p < .001). The decision tree (CHAID) method was applied to determine the time required to reposition the ETT to prevent oral mucosal PIs. The decision tree correctly classified the occurrence of oral mucosal PIs by 60.6% and the non-occurrence of oral mucosal PIs by 97.9%. Patients with parenteral nutrition and a low frequency of ETT repositioning time had a higher risk of oral mucosal PIs (p < .001).

CONCLUSIONS

Parenteral nutrition support and ETT repositioning timing were the primary risk factors for developing oral mucosal PIs. Close monitoring of endotracheally intubated patients receiving parenteral nutrition is essential, with particular attention to forming oral mucosal PIs. Additionally, repositioning the ETT at intervals of no more than 8 h may help reduce the risk of oral mucosal PI development.

RELEVANCE TO CLINICAL PRACTICE

As ICU patients are particularly vulnerable to mucosal membrane PIs, recognizing the associated risk factors is crucial for early detection and prevention. This study highlights the specific risk factors for oral mucosal PIs, equipping nurses with the knowledge to develop targeted interventions to prevent these injuries.

Development and Evaluation of an ICU Nurse Training Program on Oral Mucosal Pressure Injury Prevention and Management Using the ADDIE Model

Purpose

To construct a training course program for ICU nurses to care for oral mucosal membrane pressure injury (MMPI) and evaluate its implementation effects based on the ADDIE model.

Patients and Methods

A research team was established to construct the training course program in January 2024. According to the ADDIE model, a training course was designed and developed after the literature research and Delphi expert inquiry. The training course program was implemented in 138 ICU nurses from a tertiary A hospital in China from April to May 2024. The ICU nurses' knowledge, attitude, and practice in preventing medical device-related pressure injury in critically ill patients and the incidence of oral MMPI were compared before and after the training program.

Results

A particular training course program for the ICU nurses to care for oral MMPI was constructed in this study. It contained three aspects of particular training subjects (professional knowledge, practical skills and professional literacy) and included 16 specific training courses. One hundred and thirty-eight ICU nurses received the training course program in the hospital. The total score of MMPI knowledge-attitude-practice of the ICU nurses was (167.73±8.13) after the training, which was significantly improved compared with the score before the training (145.81±13.57) (t = 16.283, P<0.001). The incidence of oral MMPI after the training (5.94%) was significantly lower than that before training (22.93) (x 2=12.034, P<0.001).

Conclusion

The training course program for ICU nurses to care for oral MMPI based on the ADDIE module can effectively improve ICU nurses' comprehensive ability to prevent oral MMPI and reduce the incidence of oral MMPI. It can be applied in clinical nursing education and practice.

Effect of blood oxidative stress indicators on oral mucositis in patients undergoing radiotherapy for nasopharyngeal carcinoma

OBJECTIVES

To investigate the correlation of total antioxidant capacity (T-AOC), glutathione peroxidase (GSH-PX), and advanced oxidized protein product (AOPP) levels in the progression of oral mucositis (OM) during nasopharyngeal carcinoma (NPC) radiotherapy.

METHODS

This prospective study included 102 patients diagnosed with NPC and eligible for radiotherapy indications. T-AOC, GSH-PX, and AOPP were measured before treatment (T0) and during the second week (T1), fourth week (T2), and sixth week (T3) of the intensity-modulated radiation therapy (IMRT) period. Patients were categorized into severe OM (SOM) (n = 21) and Non-SOM (n = 81) groups at week 6. Serum T-AOC, GSH-PX, and AOPP levels were compared at different time periods. The trends of these markers in the two groups during the course of treatment were analyzed. Finally, stepwise logistic regression was conducted to analyze the risk factors for SOM in NPC patients undergoing IMRT.

RESULTS

At T1 and T2 of IMRT, T-AOC and GSH-PX were higher in the SOM group than in the Non-SOM group; At T3, T-AOC and GSH-PX were lower in the SOM group than in the Non-SOM group. T-AOC and GSH-PX had similar change trends in Non-SOM or SOM patients, i.e., T-AOC levels continued to increase at T2 and decreased at T3, and GSH-PX increased significantly at T2 and decreased at T3. Of interest was the fact that T-AOC and GSH-PX decreased significantly more in SOM patients than in Non-SOM patients at T3, and that AOPP levels were in a constant state of increase in SOM patients. Preoperative hypoproteinemia, the absence of oral mucosal protective agents, and the receipt of synchronous chemotherapy were independent risk factors for increasing the course of OM in patients with NPC.

CONCLUSIONS

NPC patients undergoing IMRT exhibit dynamic alterations in blood T-AOC, GSH-PX, and AOPP. Notably, the persistent elevation of these biomarkers, particularly AOPP, is significantly associated with the progression of SOM in these patients. These findings underscore the involvement of oxidative stress imbalance in the pathogenesis of oral mucositis following IMRT.

Incidence, characteristics and risk factors of endotracheal tube-related pressure injuries in intensive care units

BACKGROUND

Medical devices commonly used for the treatment and care of critically ill patients can cause pressure injuries in intensive care units (ICUs). The endotracheal tube (ETT) is one of the most common medical devices to cause pressure injuries.

AIM

This study investigated the incidence of, characteristics of and risk factors for ETT-related pressure injuries for ICU patients.

STUDY DESIGN

This study adopted a prospective descriptive research design. The sample consisted of 146 endotracheally intubated patients. Data were collected using a patient information form, an Endotracheal Tube-Related Pressure Injuries Assessment Form, the Braden Risk Assessment Tool and the Nutritional Assessment Test.

RESULTS

The study revealed that 80.14% of the patients developed ETT-related pressure injuries. Over half of the ETT-related pressure injuries appeared on Day 3 or 4 (56.41%). High body mass index was found to be associated with the development of ETT-related pressure injuries (OR: 1.15, 95% CI: 1.05-1.26, p = .003). None of the other variables were statistically significant in the development of pressure injuries.

CONCLUSIONS

The incidence of ETT-related pressure injuries was quite high in the internal, surgical and anaesthesia ICUs. High body mass index was associated with the development of ETT-related pressure injuries. Intensive care nurses should implement interventions to prevent ETT-related pressure injuries in critically ill patients receiving mechanical ventilation support.

RELEVANCE TO CLINICAL PRACTICE

ETT-related pressure injuries are common in ICU patients. High body mass index was associated with the development of ETT-related pressure injuries in critically ill patients. The skin and mucosa should be assessed for the development of ETT-related pressure injuries during the daily assessment of the patients receiving mechanical ventilation support. The ETT should be repositioned regularly, and the most suitable ETT fixation method should be used.

Development and validation of a nomogram for oral mucosal membrane pressure injuries in ICU patients: A prospective cohort study

AIMS

Establishing a nomogram to estimate the probability of oral mucosal membrane pressure injury of endotracheal tube-intubated hospitalized patients in intensive care unit.

DESIGN

Multicentre prospective cohort study.

METHODS

Using Lasso regression and COX regression, variable selection was performed on demographic, clinical and laboratory data of 1037 ICU endotracheal tube-intubated hospitalized patients from West China Hospital, to construct a nomogram. External validation was conducted on 484 ICU endotracheal tube-intubated patients from People's Hospital of Zhongjiang County.

RESULTS

Among 38 potential predictors, five variables emerged as independent predictors, integrated into the nomogram: administration of antibiotics, nutritional therapy duration, agitation, hypotension and albumin levels.

CONCLUSIONS

We established a nomogram based on the hospital characteristics of ICU endotracheal tube-intubated patients, aiding in the prediction of the occurrence of oral mucosal membrane pressure injury.

REPORTING METHOD

The study followed TRIPOD guidelines.

RELEVANCE TO CLINICAL PRACTICE

The nomogram we developed can assist clinical worker in better identifying at-risk patients and risk factors. It enables the implementation of evidence-based nursing interventions in care to prevent the development of oral mucosal membrane pressure injury.

TRIAL REGISTRATION

The study has been registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn) under registration number ChiCTR2200056615.

Relationship between oral lesions and severe SARS-CoV-2 infection in intensive care unit patients

OBJECTIVE

Oral lesions received increased attention as likely new signs or secondary manifestations of COVID-19. Therefore, we clinically examined oral cavity of patients with COVID-19 and investigated oral lesions and patient comorbidities as possible risk factors of COVID-19 disease outcome.

METHODS

From January to March 2022, a prospective study was conducted by recruiting all COVID-19 patients admitted to the Intensive Care Unit and Respiratory Intensive Care Unit of Maxi-Emergencies Hospital in Bari, Italy.

RESULTS

From the enrolled 103 COVID-19 patients, 46.6% were females and 53.4% were males. Findings show that risk of presenting with severe COVID-19 disease was higher in patients who developed oral lesions related to COVID-19 than those with no oral lesions (RR = 7.998, p = .002). Next, patients with concomitant autoimmune diseases were at higher risk of a negative COVID-19 disease outcome than those without comorbidities (OR = 8.838, p = .026).

CONCLUSIONS

COVID-19-related lesions of oral mucosa should not be ignored as they can be early and easily detectable signs of severe COVID-19 disease condition, thus, serving as a prevention measure for any potential unfortunate event. Findings of this study, without implying causation, offer a direction for future investigations that aim to confirm the presence of specific oral lesions in COVID-19 patients as signs of severe disease progression.

Impact of two endotracheal tube fixation on the incidence of peri-oral lesions: Elastic adhesive strips versus cord in a protective sheath. Study protocol for a cluster cross-over randomized trial

BACKGROUND

Endotracheal tube fixation in ventilated patients must be appropriate to ensure security during mechanical ventilation and prevent skin lesions. The incidence of endotracheal tube-caused pressure ulcers ranges from 7% to 45%. Various endotracheal tube fixations are used in intensive care units (ICUs) worldwide. By pressure exercised on the skin, these systems could lead to mucosal and skin peri-oral lesions. The main objective of this study is to evaluate the impact of the two fixation systems most commonly used in French ICUs (adhesive elastic band versus fixation cord with PolyVinyl Chloride (PVC) sheath) on the incidence of these peri-oral skin lesions.

METHODS

This studyis a multicenter, open-label, controlled, superiority, cluster cross-over randomized trial. 768 patients will be recruited in the 16 ICUs involved. The inclusion of patients will be carried out over two 12-month periods. Each site begins with one of the evaluated fixation systems: elastic adhesive tape or cord associated with a protective sheath. After a 4-month break, each site switches to the other fixation system. The primary outcome is the development of at least one peri-oral lesion during the first ten days of maintaining an orally inserted endotracheal tube. The presence of lesions is assessed by a blinded adjudication committee using photographs taken daily.

DISCUSSION

This study is the first multicenter, randomized trial designed to evaluate the impact of elastic adhesive tape versus fixation cord with PVC sheath on the incidence of peri-oral lesions. The results will provide data which could change and standardize care practices.

TRIAL REGISTRATION

https://www.clinicaltrials.gov. Reference number: NCT04819425.

Mucosal membrane pressure injury in intensive care units: A scoping review

AIM

To describe published work on the current situation of mucosal membrane pressure injury of patients in the intensive care unit.

BACKGROUND

Device-related pressure injuries in critically ill patients are mostly focused on skin surface injuries, and less attention is paid to mucosal membrane pressure injury.

METHODS

We searched PubMed, Embase, Web of Science, CINAHL, and Cochrane Library from database construction until March 1, 2023. Two researchers independently screened and extracted data.

RESULTS

Eighteen articles met our criteria and were published in 2014-2023. The included studies showed that the incidence of mucosal membrane pressure injury in critically ill patients ranged from 0.83% to 88.2%, and the prevalence ranged from 0.16% to 55.6%. The most frequently reported site of mucosal injury is the oral mucosa, followed by the nasal mucosa. Ten studies used Braden to assess the risk of mucosal membrane pressure injury, and only six studies reported specific stages of mucosal membrane pressure injury. Thirteen studies described 30 risk factors for mucosal membrane pressure injury, with albumin being the most frequently reported risk factor, followed by the vasoconstrictive drugs use. Thirty risk factors were summarized in six aspects: medical device-related factors, disease-related factors, treatment- related factors, physiological and biochemical parameters, demographic-related factors, and microbial colonisation.

CONCLUSIONS

The incidence or prevalence of mucosal membrane pressure injury varies widely, and specific risk assessment tools and standardized staging criteria need to be further determined. The risk factors of mucosal membrane pressure injury involve multiple aspects, and some risk factors have only been explored in few studies and need to be further verified, in order to detect the risk group of mucosal membrane pressure injury early and take targeted preventive measures.

IMPLICATIONS FOR CLINICAL PRACTICE

We synthesized the current research status of mucosal membrane pressure injury in critically ill patients, which can provide a valuable reference for the clinical staff to develop preventive and management measures for such patients.

Quantitative oral health assessments in mechanically ventilated patients: A scoping review

BACKGROUND

Oral health is a key contributor to a person's overall health. Previous studies indicate that oral health deteriorates throughout ventilation and may contribute to the development of ventilator-associated pneumonia (VAP). Oral health at the time of initial ventilation may impact on this deterioration.

AIMS

To determine the quantitative clinical assessment methods used to measure oral health and what is currently known regarding the oral health of patients at the time of initial ventilation.

STUDY DESIGN

A systematic literature search using electronic bibliographic databases MEDLINE/PubMed, Embase, CINAHL, and the Cochrane Library was undertaken for this scoping review. Studies were included if patients were >18 years old and mechanically ventilated for <48 h at the time of the first oral assessment.

RESULTS

In total, 12 studies were included. The review demonstrates a limited understanding of clinical oral health at the time of initial ventilation. Significant variation in both assessment methods and reporting of oral health makes comparison of results difficult resulting in a poor overall understanding of oral health at the time of intubation.

CONCLUSION

Standardized assessment and reporting methods may improve clinical application of findings and help direct future research. We suggest developing a core outcome set to ensure consistent use of assessment tools as well as standardized reporting of results.

RELEVANCE TO CLINICAL PRACTICE

It is essential that a good understanding of oral health at the time of initial ventilation is gained so that patients receive more targeted oral hygiene intervention in ICU, potentially leading to improved patient outcomes.

Oral clinical findings and intensive care unit prognostic scores

OBJECTIVE

Hospitalisation in intensive care unit (ICU) may cause changes in oral environment, which may influence patients' health status. The aim of this study was to evaluate the frequency of intraoral and extraoral findings observed during ICU admission, and to verify if there is an association with clinical prognosis scores.

METHODS

Data regarding clinical characteristics of patients hospitalised in an ICU were collected from medical records. The prognostic scores Sepsis Related Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score (SAPS 3) were estimated with data collected from admission and SOFA on the day of the oral examination as well. Data on oral mucosa lesions, saliva, dental condition and oral hygiene were evaluated during oral examinations.

RESULTS

The association of oral findings with prognostic scores was statistically verified. The majority (92.2%) of the 170 evaluated patients showed extraoral or intraoral findings during ICU admission. The most frequent findings were chapped and crusted lips, coated tongue, pale mucosa, haemorrhagic lesions, candidiasis, depapillated tongue and traumatic lesions. There were significant higher prognostic scores in the presence of the following extraoral and intraoral findings: crusted and ulcerated lips, haemorrhagic lesions, jaundice, spontaneous oral bleeding, coated and depapillated tongue. Median SAPS 3 was higher in patients with poor oral hygiene.

CONCLUSIONS

Oral findings were frequent in the population of patients hospitalised in the ICU and some of them were associated with worse prognostic scores. Routine oral examinations must be performed in hospitalised patients from ICUs for detection of oral markers of worse clinical prognosis.

Oral status and affecting factors in Iranian ICU patients: a cross-sectional study

BACKGROUND

Oral care is crucial in intensive care units (ICUs). Meanwhile, this action is not well-performed, therefore, mouth cavity-associated disorders cause serious outcomes, e.g. ventilator-dependent pneumonia. Considering a lack of studies in Iran on this subject, this study aimed to determine the oral status and affected factors in ICU patients in Iran.

METHODS

In a cross-sectional study in 2019, we assessed the oral status of 138 patients admitted to the ICUs in the Kermanshah and Ilam provinces by census method. The tools were a demographic and clinical characteristics checklist, and Beck's oral status assessment scale (BOAS). The researcher investigated the condition of the patient's mouth, and their records. Data were analyzed using descriptive and inferential statistics.

RESULTS

In this study, the prevalence of moderate and severe disorders of the lips, gums and oral mucosa, tongue, teeth, and saliva were 14.4, 26.1, 16.6, 49.3, and 34.8 percent, respectively. Six percent of patients had a normal oral condition. Oral status had a significant relationship with education level, age, marital status, brushing teeth, NG tube, and consciousness level.

CONCLUSION

Compared to other studies, the prevalence of oral cavity disorders in ICU patients of the Ilam and Kermanshah provinces was high. It mandates paying crucial attention to nurses' continued education, using standard guidelines, and applying new facilities. Moreover, it is mandated for periodical visits of patients by a dentist in ICUs.

Oral lesions in patients with COVID-19 hospitalized in an intensive care unit: a case-series study

This study evaluated the presence of oral lesions in patients with COVID-19 hospitalized in an intensive care unit (ICU). Data included demographic, clinical, and laboratory information. Clinical assessment of the oral cavity was performed on the 2 nd and 5 th days of orotracheal intubation. Thirty-eight patients were evaluated and 16 (42.1%) presented oral lesions during their ICU stay. The median age and length of stay were 75 years and 15 days, respectively. Among the patients with oral lesions, ulcerative oral lesions were reported in 14 (87.5%) patients, of which 11 (78.6%) were found on the lips. This study highlights the importance of oral examination for patients admitted to the ICU with COVID-19.

Lack of direct association between oral mucosal lesions and SARS-CoV- 2 in a cohort of patients hospitalised with COVID-19

Background

COVID-19 is a disease affecting various human organs and systems, in which the virus seeks to interact with angiotensin-converting enzyme 2 receptors. These receptors are present in the oral cavity, but the direct relationship between such an interaction and possible oral manifestations of COVID-19 is still unclear.

Aim

The present study evaluated oral manifestations in a cohort of COVID-19 patients during the period of hospitalisation.

Methods

In total, 154 patients presenting moderate-to-severe forms of COVID-19 had their oral mucosa examined twice a week until the final outcome, either discharge or death. The oral alterations observed in the patients were grouped into Group 1 (pre-existing conditions and opportunistic oral lesions) and Group 2 (oral mucosal changes related to hospitalization).

Results

Oral lesions found in the patients of Group 1 are not suggestive of SARS-CoV-2 infection as they are mainly caused by opportunistic infections. On the other hand, oral alterations found in the patients of Group 2 were statistically (P < 0.001) related to intubation and longer period of hospitalisation.

Conclusion

It is unlikely that ulcerative lesions in the oral cavity are a direct manifestation of SARS-CoV-2 or a marker of COVID-19 progression.

Development and Effectiveness of a Clinical Decision Support System for Pressure Ulcer Prevention Care Using Machine Learning: A Quasi-experimental Study

This study was conducted to develop and evaluate the effectiveness of a clinical decision support system for pressure ulcer prevention on clinical (performance, visual discrimination ability, and decision-making ability) and cognitive (knowledge and attitude) workflow. After developing a clinical decision support system using machine learning, a quasi-experimental study was used. Data were collected between January and April 2020. Forty-nine RNs who met the inclusion criteria and worked at seven tertiary and five secondary hospitals participated. A clinical decision support system was provided to the intervention group during the same period. Differences in outcome variables between the two groups were analyzed using t tests. The level of pressure ulcer prevention nursing performance and visual differentiation ability of skin pressure and oral mucosa pressure ulcer showed significantly greater improvement in the experimental group compared with the control group, whereas clinical decision making did not differ significantly. A clinical decision support system using machine learning was partially successful in performance of skin pressure ulcer prevention, attitude, and visual differentiation ability for skin and oral mucosa pressure ulcer prevention. These findings indicated that a clinical decision support system using machine learning needs to be implemented for pressure ulcer prevention.

The impact of two distinct endotracheal tube fixation on the formation of pressure ulcer in the intensive care unit: A randomised controlled trial

The most common pressure ulcer associated with medical devices in the ICU is pressure injury associated with the endotracheal tube. We aimed to scrutinise the effects of two different techniques of endotracheal tube securement used in the ICU on the occurrence of pressure ulcers. This randomised clinical trial was conducted in 60 patients, 30 of which were intervention and 30 experimental, admittedin the ICU of a training and research hospitaldata were collected using the descriptive and clinical characteristics from the Braden Scale for predicting Pressure Sore Risk, the Pressure Ulcer Scale for healing, The International Staging System for Pressure Injuries and the Eilers Oral Assessment Guide. Based on the Braden Scale scores of the patients, we found that 98.3% of the cases were in the high‐risk group before and after the intervention. We also found that the recovery was higher among patients in whom the bandage fixation method was applied compared to those in whom the fixation was done with an endotracheal tube holder.

Risk factors for oral alterations in intensive care unit patients: A pilot cohort study

BACKGROUND

Several studies evidenced the presence of oral alterations in ICU patient. However, data about identification of their risk factors in ICU patients is scarce, especially due to the lack of longitudinal prospective studies. Here, we evaluate the risk factors for the development of oral alterations in a group of ICU patients through a prospective longitudinal cohort.

METHODS

During May-December 2019, 43 ICU patients in a tertiary hospital in Brazil were evaluated. Medical record reviews and oral examinations of each patient were made by 3 dentists in five distinct moments.

RESULTS

Among all patients, 53.5% (n = 23) were female, with a mean age of 59.8 years (±17.4). The incidence of oral alterations was 51.2% (35.6%-66.8%) and among these (n = 22), hyposalivation (n = 9; 40.9%), and lingual biofilm accumulation (n = 9; 40.9%) were the most common. The mean age of the group with oral alterations (66.9 years) was higher compared to the group without alterations (52.3 years). Furthermore, male patients (p = 0.02), older than 60 years (p = 0.004) and treated with mechanical ventilator (p = 0.03) had a higher risk of oral alterations.

CONCLUSIONS

Systemic parameters, as age and mechanical ventilator, could influence the oral environment of ICU patients.

Exploring medical device-related pressure injuries in a single intensive care setting: A longitudinal point prevalence study

OBJECTIVES

To report longitudinal prevalence rates of device-related pressure injuries in critically ill adult patients in the intensive care unit and to explore the patient characteristics associated with the development of device related pressure injuries.

RESEARCH DESIGN

A prospective observational design where observations of patients' skin integrity were conducted on one day each week for 52 weeks.

SETTING

The study was conducted in the 36-bed ICU of a major metropolitan tertiary referral hospital in Queensland, Australia. The sample included all patients aged 18 years or older admitted to the intensive care unit before midnight on the day preceding the observation, with a medical device in situ.

MAIN OUTCOME MEASURES

The primary outcome measure was device related pressure injuries identified at the weekly observations and defined as a pressure injury found on the skin or mucous membrane with a history of medical device in use at the location of the injury. Patient demographic and clinical characteristics were recorded.

RESULTS

Over the study period, 11.3% (71/631) of patients developed at least one hospital-acquired DRPI. The most common devices associated with injury were nasogastric/nasojejunal tubes (41%) and endotracheal tubes (27%). Significant predictors of device related pressure injuries were the total number of devices (OR 1.230, 95% CI 1.09-1.38, p < 0.001), the length of time in the ICU (OR 1.05, 95% CI 1.02-1.09, p = 0.003), male sex, (OR 2.099, 95% CI 1.18-3.7, p = 0.012), and increased severity of illness score on admission (OR 1.044, 95% CI 1.01-1.09, p = 0.013).

CONCLUSION

Device related pressure injuries are an all-too-common iatrogenic problem for this vulnerable patient cohort.

Systematic review: Incidence and prevalence of mucous membrane pressure injury in adults admitted to acute hospital settings

Mucous membrane pressure injury (MMPI) is associated with a history of medical device use at the site of injury. The current international guideline recommends they should be reported in incidence and prevalence studies. The aim of this systematic review was to analyse the incidence and prevalence of hospital-acquired MMPI in adults admitted to acute hospital settings. Database searches (EBSCO CINAHL Complete, EBSCO Medline Complete, Embase, Scopus and Web of Science) were undertaken between October 2019 and February 2021, using search terms related to hospital-acquired, mucosal and device-related pressure injury/ulcer incidence and prevalence. Searches were limited to the English language. Articles published between 2008 and 2020, reporting incidence or prevalence of mucous membrane or medical device-related pressure injury in non-interventional samples were selected. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. Twenty-one studies met inclusion criteria; most provided incidence data. No studies were found that specifically reported MMPI incidence or prevalence. It was possible to calculate incidence or prevalence from four studies; all were in intensive care settings. MMPI incidence of 0.8% and 30.4%, and prevalence of 1.7% and 3.7% were found. One study provided data that enabled calculation of prevalence of 0.1% in a non-intensive care sample. Only one other study provided specific data about MMPI. It is concluded that there is insufficient evidence available to enable estimation of MMPI incidence or prevalence in either acute hospital or intensive care settings.

Incidence and risk factors of medical device-related pressure injuries among patients undergoing prone position spine surgery in the operating room

AIM

We aimed to investigate the incidence rate and risk factors of medical device-related pressure injuries (MDRPIs) among patients undergoing prone position spine surgery.

MATERIALS AND METHODS

This was a prospective observational study of 147 patients who underwent spine surgery in an orthopaedic hospital in Korea. The incidence of MDRPI according to intrinsic and extrinsic factors was assessed using the independent t-, χ² -, or Fisher's exact tests. A logistic regression analysis was performed exclusively for MDRPI areas with an incidence rate >5%.

RESULTS

The mean incidence rate of overall MDRPI was 27.4%, while that of MDRPI by Wilson frame, bi-spectral index, and endotracheal tube (ETT) was 56.5%, 52.4%, and 9.5%, respectively. The risk factors under Wilson frame were operation time and body mass index classification. Compared to their normal weight counterparts, those who were underweight, overweight, and obese had a 46.57(95% CI: 6.37-340.26), 3.96 (95% CI: 1.13-13.86), and 5.60 times (95% CI: 1.62-19.28) higher risk of developing MDRPI, respectively. The risk factors by bi-spectral index were sex, operation time, and the American Society of Anaesthesiologists classification. Compared to ETT intubation of <2 h, the risk of MDRPI increased by 7.16 times (95% CI: 1.35-38.00) and 7.93 times (95% CI: 1.45-43.27) for<3 and ≥3 h' duration, respectively.

CONCLUSION

The difficulty of device repositioning can increase the incidence of MDRPI, and prolonged surgery was a significant risk factor. Thus, appropriate planning and correct equipment utilization is needed during prone position spine surgeries.

Effects of Attitude, Barriers/Facilitators, and Visual Differentiation on Oral Mucosa Pressure Ulcer Prevention Performance Intention

Oral mucosa pressure ulcers (PUs) can result in frequent pain and discomfort, and have negative effects on quality of life. We aimed to examine attitude, barriers/facilitators of oral mucosa PU prevention, the ability to differentiate oral mucosa PU, and to identify factors influencing PU prevention performance intention. This was a cross-sectional descriptive study of 112 nurses in seven tertiary hospitals and three secondary hospitals. The data collection period was from August to December 2018. For data analysis, descriptive statistics, t-test, ANOVA, Pearson's correlation coefficient, and multiple regression were used. The mean score of attitudes toward oral mucosa PU prevention was 3.74 ± 0.39. Barriers to oral mucosa PU prevention were 5.65 ± 1.66, and facilitators were 5.35 ± 1.34. The mean correct answer rate of visual differentiation ability was 13%. The factors affecting intention to perform oral mucosa PU prevention were facilitators of oral mucosa PU prevention (β = 0.32, p = 0.001) and attitude (β = 0.26, p = 0.005). To increase intention to perform oral mucosa PU prevention, positive attitudes and enhanced facilitators should be encouraged. Therefore, standardized guidelines and strategies, such as educational opportunities and allocation of resources and personnel focused on oral mucosa PU prevention, need to be provided.

Eruptions and related clinical course among 296 hospitalized adults with confirmed COVID-19

Background

Limited information exists on mucocutaneous disease and its relation to course of COVID-19.

Objective

To estimate prevalence of mucocutaneous findings, characterize morphologic patterns, and describe relationship to course in hospitalized adults with COVID-19.

Methods

Prospective cohort study at 2 tertiary hospitals (Northwell Health) between May 11, 2020 and June 15, 2020.

Results

Among 296 hospitalized adults with COVID-19, 35 (11.8%) had at least 1 disease-related eruption. Patterns included ulcer (13/35, 37.1%), purpura (9/35, 25.7%), necrosis (5/35, 14.3%), nonspecific erythema (4/35, 11.4%), morbilliform eruption (4/35, 11.4%), pernio-like lesions (4/35, 11.4%), and vesicles (1/35, 2.9%). Patterns also showed anatomic site specificity. A greater proportion of patients with mucocutaneous findings used mechanical ventilation (61% vs 30%), used vasopressors (77% vs 33%), initiated dialysis (31% vs 9%), had thrombosis (17% vs 11%), and had in-hospital mortality (34% vs 12%) compared with those without mucocutaneous findings. Patients with mucocutaneous disease were more likely to use mechanical ventilation (adjusted prevalence ratio, 1.98; 95% confidence interval, 1.37-2.86); P < .001). Differences for other outcomes were attenuated after covariate adjustment and did not reach statistical significance.

Limitations

Skin biopsies were not performed.

Conclusions

Distinct mucocutaneous patterns were identified in hospitalized adults with COVID-19. Mucocutaneous disease may be linked to more severe clinical course.

Risk prediction models for the development of oral-mucosal pressure injuries in intubated patients in intensive care units: A prospective observational study

PURPOSE

Oral-mucosal pressure injury (PI) is the most commonly encountered medical device-related PIs. This study was performed to identify risk factors and construct a risk prediction model for oral-mucosal PI development in intubated patients in the intensive care unit.

METHODS

The study design was prospective, observational with medical record review. The inclusion criteria stipulated that 1) participants should be > 18 years of age, 2) there should be ETT use with holding methods including adhesive tape, gauze tying, and commercial devices. Data of 194 patient-days were analysed. The identification and validation of risk model development was performed using SPSS and the SciKit learn platform.

RESULTS

The risk prediction logistic models were composed of three factors (bite-block/airway, commercial ETT holder, and corticosteroid use) for lower oral-mucosal PI development and four factors (commercial ETT holder, vasopressor use, haematocrit, and serum albumin level) for upper oral-mucosal PI development among 10 significant input variables. The sensitivity and specificity for lower oral-mucosal PI development were 85.2% and 76.0%, respectively, and those for upper oral-mucosal PI development were 60.0% and 89.1%, respectively. Based on the results of the machine learning, the upper oral-mucosal PI development model had an accuracy of 79%, F1 score of 88%, precision of 86%, and recall of 91%.

CONCLUSIONS

The development of lower oral-mucosal PIs is affected by immobility-related factors and corticosteroid use, and that of upper oral-mucosal PIs by undernutrition-related factors and ETT holder use. The high sensitivities of the two logit models comprise important minimum data for positively predicting oral-mucosal PIs.

Which endotracheal tube location minimises the device-related pressure ulcer risk: The centre or a corner of the mouth?

The use of an endotracheal tube (ETT), which is required for any mechanical ventilation procedure, involves an inherent risk for facial skin, lip, and mucosal pressure ulcers. The ETT is one of the most common devices associated with medical device-related pressure ulcers (MDRPUs) among surgical and intensive care unit patients. In the present work, we investigated, for the first time in the literature, the biomechanical effects of the presence and positioning of an ETT in the mouth on lip, mucosal and surrounding facial skin loads. Using two anatomically realistic finite element model variants, two ETT locations were simulated and compared, at the centre versus the corner of the mouth. Our study shows that a central location of the ETT inflicted greater lip and mucosal stress values, but a corner location caused a more widespread and diffused lip, mucosal and facial skin stress exposure. Accordingly, we cannot recommend a "safer" location for ETTs in the mouth; additional preventative measures such as dedicated dressing materials or special cushioning pads applied prophylactically, should be developed to protect from MDRPUs associated with ETT usage. The present modelling framework can be used to study the biomechanical efficacy of such protective technologies, and can therefore aid in the prevention of ETT-caused MDRPUs.