Unavoidable Pressure Ulcers

Enhanced Skin Assessment Methodology to Detect Early Tissue Damage and Prevent Pressure Injuries

PURPOSE

The purpose of this study was to evaluate a skin assessment technique, subepidermal moisture (SEM) assessment, to assess, identify, and prevent pressure injuries (PIs) in critically ill adults.

DESIGN

This was a retrospective, descriptive, comparative research study.

SUBJECTS AND SETTING

The sample comprised 69 critically ill adults; their mean age was 58.8 years (SD 18.1 years). The majority were male (n = 40, 58%), 29 (42%) were African American (AA), and 36 (52%) were White. The study setting was a surgical trauma intensive care unit (STICU) in a southern US Gulf Coast academic level I trauma hospital. Data were collected from September to November 2021.

METHODS

We conducted a retrospective medical record review of subjects who had undergone SEM assessment. We also collected demographic and pertinent clinical information, including Braden Scale cumulative scores and subscale scores, documented PI prevention interventions, and PI occurrence and characteristics if developed within 7 days of SEM measurement. We also evaluated whether PI prevention interventions were appropriate. To examine nurse perception of the SEM device, we conducted a web-based survey of nurses providing care in our facility's STICU. Comparison of responses was done using Fisher's test or Chi-square test, and the mean responses from groups were compared using t test.

RESULTS

Thirty-five (57%) subjects had a sacral SEM delta ≥0.6; 14 (40%) were AA; 20 (57%) were White; and 11 (31%) had a hospital-acquired PI (HAPI) or present-on-admission (POA) PI. Among the 14 HAPI and POA PI subjects with sacral SEM delta, 11 (79%) had sacral SEM delta ≥0.6. Among 26 AA subjects with sacral SEM delta, 5 had a HAPI or POA PI, and of those, 4 (80%) had sacral SEM delta ≥0.6. A significant and negative correlation was observed between cumulative Braden Scale scores on day 2 and sacral SEM delta (r = -0.28, P = .03) and R heel delta (r = -0.29, P = .03) scores, indicating higher PI risk. Of the 35 patients with a sacral SEM delta ≥0.6, 24 (69%) subjects did not have appropriate PI prevention interventions. Nurses (n = 13) indicated that the SEM device was easy to use and helped them perform an accurate skin assessment on patients with darker skin tones.

CONCLUSIONS

This study demonstrates that SEM technology is beneficial to address racial disparities in skin assessment, enhance skin assessment accuracy beyond existing PI care, improve the accuracy of risk assessment, and promote appropriate location-specific PI prevention interventions.

Prevalence and incidence of pressure injuries among older people living in nursing homes: A systematic review and meta-analysis

BACKGROUND

Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population.

OBJECTIVES

To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s).

DESIGN

Systematic review and meta-analysis.

SETTING(S)

Nursing homes, aged care, or long-term care facilities.

PARTICIPANTS

Older people, 60 years and older.

METHODS

Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I2 statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression.

RESULTS

3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6-13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2-8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5-26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4-13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection.

CONCLUSION

The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries.

REGISTRATION NUMBER

PROSPERO CRD42022328367.

TWEETABLE ABSTRACT

Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals.

Factors Associated with Intensive Care Units' Nurses Frequency of Performing Pressure Injury Prevention: A Cross-sectional Study

AIM

To explore factors associated with frequency of performing pressure injury prevention measures among a sample of intensive care units' nurses.

BACKGROUND

Pressure injuries may be unavoidable in specific circumstances; however, most pressure injuries may be considered preventable. Nursing actions at the point of care play a significant role in shaping pressure injury prevention.

METHODS

A cross-sectional, descriptive correlational design was used. Using convenience sampling method, 162 intensive care units' nurses were recruited from three hospitals in Riyadh, Saudi Arabia. The participants completed a survey that included Nurses' Practice of Pressure Ulcer Prevention Questionnaire, Pressure Ulcer Knowledge Assessment Tool, Attitude toward Pressure Ulcer Prevention, Pressure Ulcer Prevention Barriers instrument, and Intention to Use Pressure Injury Preventive Measures instrument. Data were analyzed using descriptive and inferential statistics.

RESULTS

Nurses lack of knowledge about pressure injury preventions. However, they possessed positive attitudes toward pressure injury preventions. Nurses faced some barriers to prevent pressure injuries. Most nurses agreed that there was social pressure to prevent pressure injury. They had an intention to use preventive measures to prevent pressure injury. Nurses performed pressure injury prevention frequently. The bivariate and multivariate analyses showed only barriers to prevent pressure injury were negatively associated with frequency of performing pressure injury prevention.

CONCLUSIONS

Several factors that may influence ICU nurses' behavior to perform PIPs have been identified. The participants reflected positive attitude, positive social pressure, and intention to perform PIPs. Nevertheless, they need to improve their knowledge of PIPs and reduce the barriers prevented them from performing PIPs.

Pressure injuries in Australian public hospitals: A cost of illness study

BACKGROUND

Pressure injuries are a leading hospital adverse event, yet they are mostly preventable. Understanding their financial costs will help to appreciate the burden they place on the health system and assist in better planning and management of health expenditures to prevent pressure injuries.

OBJECTIVE

To estimate the cost of pressure injuries in Australian public hospitals in 2020 demonstrating its economic burden in a well-resourced health system.

METHODS

A cost of illness study with a 12-month time horizon was conducted. Resource use for the treatment of pressure injuries and productivity loss due to pressure injuries were derived using a bottom-up approach. Parameters of the cost estimates were obtained from secondary sources and literature syntheses. A simulation with 10,000 draws was used to generate statistical properties of the cost estimates.

RESULTS

Based on a prevalence of 12.9%, the total cost of pressure injuries in Australian public hospitals was $9.11 billion [95% confidence intervals: 9.02, 9.21]. The two largest shares of costs were accounted for by the opportunity cost of excess length of stay of $3.60 billion [3.52, 3.68] and treatment costs of $3.59 billion [3.57, 3.60]. Productivity loss associated with pressure injuries amounts to $493 million [482, 504]. Hospital-acquired pressure injuries account for a total of $5.50 billion [5.44, 5.56], whereas pressure injuries present on admissions costed $3.71 billion [3.70, 3.72]. In terms of severity, Stage 2 pressure injuries contributed the most to total treatment costs, total excessive length of stay, and total loss of healthy life years. Australian society is willing to pay $1.43 billion [1.40, 1.45] to save 6,701 [6,595; 6,807] healthy life years lost by pressure injury.

CONCLUSIONS

Reducing preventable pressure injuries and stopping the progression of Stage 1 pressure injuries will likely result in an immense cost-saving for Australia and will likely have similar benefits for other countries with comparable profiles.

TWEETABLE ABSTRACT

Australian public hospital study provides comprehensive analysis of the cost of pressure injury, including estimates of direct and indirect medical costs, and indirect non-medical costs - such as productivity and quality of life.

Pressure Injuries in Critical Care Patients in US Hospitals: Results of the International Pressure Ulcer Prevalence Survey

PURPOSE

The purpose of this secondary analysis was to examine pressure injury (PI) prevalence, PI risk factors, and prevention practices among adult critically ill patients in critical care units in the United States using the International Pressure Ulcer Prevalence™ (IPUP) Survey database from 2018 to 2019.

DESIGN

Observational, cohort study with cross-sectional data collection and retrospective data analysis.

SUBJECTS AND SETTING

The sample comprised 41,866 critical care patients drawn from a sample of 296,014 patients in US acute care facilities who participated in the 2018 and/or 2019 IPUP surveys. The mean age among critical care patients was 63.5 years (16.3) and 55% were male. All geographic regions of the United States were represented in this sample, with the greatest percentages from the Southeast (47.5%) and Midwest (17.5%) regions.

METHODS

Overall critical care PI prevalence and hospital-acquired PI (HAPI) rates were obtained and analyzed using the 2018/2019 IPUP survey database. Critical care PI risk factors included in the database were analyzed using frequency distributions. Prevention practices among critically ill patients were analyzed to evaluate differences in practices between patients with no PIs, superficial PIs (stage 1, stage 2), and severe PIs (stage 3, stage 4, unstageable, deep tissue pressure injury).

RESULTS

The overall PI prevalence for critical care patients was 14.3% (n = 5995) and the overall HAPI prevalence was 5.85% (n = 2451). In patients with severe HAPIs, the most common risk factors were diabetes mellitus (29.5%), mechanical ventilation (27.6%), and vasopressor agents (18.9%). Significant differences between patients with no PIs as compared to those with superficial or severe HAPIs (P = .000) for all prevention practices were found.

CONCLUSIONS

Study findings support the gaps elucidated in previous critical care studies on PI development in this population. The 2 most persistent gaps currently challenging critical care practitioners are (1) accurate risk quantification in this population and (2) the potential for unavoidability in PI development among critically ill patients.

Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study

PURPOSE

To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs).

DESIGN

Retrospective, matched, case-control design.

SUBJECTS/SETTING

Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016.

METHODS

Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score).

RESULTS

All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization.

CONCLUSION

Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.

Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study

PURPOSE

The purpose of this study was to examine clinical characteristics and risk factors for critically ill patients who develop pressure injuries and identify the proportion of validated unavoidable pressure injuries associated with the proposed risk factors for acute skin failure (ASF).

DESIGN

Retrospective case-control comparative study.

SUBJECTS AND SETTING

The sample comprised adult critically ill participants hospitalized in critical care units such as surgical, trauma, cardiovascular surgical, cardiac, neuro, and medical intensive care and corresponding progressive care units in 5 acute care hospitals within a large Midwestern academic/teaching healthcare system. Participants who developed hospital-acquired pressure injuries (HAPIs) and patients without HAPIs (controls) were included.

METHODS

A secondary analysis of data from a previous study with HAPIs and matching data for the control sample without HAPIs were obtained from the electronic health record. Descriptive and multivariate logistic regression analyses were conducted.

RESULTS

The sample comprised 475 participants; 165 experienced a HAPI and acted as cases, whereas the remaining 310 acted as controls. Acute Physiology and Chronic Health Evaluation (APACHE II) mean score (23.8, 8.7%; P < .001), mortality (n = 45, 27.3%; P = .002), history of liver disease (n = 28, 17%; P < .001), and unintentional loss of 10 lb or more in 1 month (n = 20, 12%; P = .002) were higher in the HAPI group. Multivariate logistic regression analysis identified participants with respiratory failure (odds ratio [OR] = 3.00; 95% confidence interval [CI], 1.27-7.08; P = .012), renal failure (OR = 7.48; 95% CI, 3.49-16.01; P < .001), cardiac failure (OR = 4.50; 95% CI, 1.76-11.51; P = .002), severe anemia (OR = 10.89; 95% CI, 3.59-33.00; P < .001), any type of sepsis (OR = 3.15; 95% CI, 1.44-6.90; P = .004), and moisture documentation (OR = 11.89; 95% CI, 5.27-26.81; P <.001) were more likely to develop a HAPI. No differences between unavoidable HAPI, avoidable HAPI, or the control group were identified based on the proposed ASF risk factors.

CONCLUSION

This study provides important information regarding avoidable and unavoidable HAPIs and ASF. Key clinical characteristics and risk factors, such as patient acuity, organ failure, tissue perfusion, sepsis, and history of prior pressure injury, are associated with avoidable and unavoidable HAPI development. In addition, we were unable to support a relationship between unavoidable HAPIs and the proposed risk factors for ASF. Unavoidability of HAPIs rests with the documentation of appropriate interventions and not necessarily with the identification of clinical risk factors.

Avoidable and Unavoidable Pressure Injuries Among Residents Living in Nursing Homes: A Retrospective Study

PURPOSE

The aim of this study was to describe the prevalence of unavoidable pressure injuries (UPIs) in residents of nursing homes (NHs) and characteristics associated with UPIs.

DESIGN

A retrospective study.

SUBJECTS AND SETTING

Residents 65 years or older residing in any of 105 NHs in the Friuli Venezia Giulia region of Italy between January and December 2013.

METHODS

Database search comprised of a multidimensional assessment of NH residents.

RESULTS

Data from 7950 residents were reviewed, 925 (11.6%) of whom had 1 or more documented pressure injuries (PIs). Among these, 221 (23.9%) residents met criteria for avoidable PIs (APIs) and 704 (76.1%) for UPIs. Residents with UPIs were more frequently hemodynamically unstable, terminally ill, and had medical devices (all Ps < .001) than residents with APIs. Moreover, residents with UPIs showed higher functional, cognitive, and mood impairments compared to residents with APIs (all Ps < .001).

CONCLUSIONS

Our findings suggest a high prevalence of UPIs compared to APIs among residents residing in NHs in one region of Italy. Additional research is needed to establish the prevalence of UPIs among NH residents country-wide, as well as determine specific criteria that identify UPIs in long-term care settings and increase consistency in prevalence and incidence measurement models.

Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years

BACKGROUND

Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings.

OBJECTIVE

Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations.

DESIGN

Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality Indicators^Ⓡ 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay.

PARTICIPANTS

We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period.

METHODS

Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers.

RESULTS

An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively.

CONCLUSION

Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

Measuring the quality of pressure ulcer prevention: A systematic mapping review of quality indicators

The aim of this study was to provide a systematic overview of available pressure ulcer prevention quality indicators and to evaluate the underlying empirical evidence. A systematic mapping review was conducted with combined searches in Embase and Medline, and websites of relevant institutions and organisations. The eligibility criteria were clear use of the term "quality indicator" regarding pressure ulcer prevention; English or German language; and all settings, populations, and types of resources, including articles, brochures, and online material. In total, n = 146 quality indicators were identified. Most indicators were published in the United States (n = 50). The majority of indicators was developed for the hospital setting (n = 102). Process indicators were the most common (n = 71), followed by outcome indicators (n = 49). Less than half of identified indicators appeared to be practically used. Evidence supporting the validity and reliability were reported for n = 25 and n = 30 indicators respectively. The high number of indicators demonstrate the importance of measuring pressure ulcer prevention quality. This is not an indicator of our ability to accurately measure and evaluate this construct. There is an urgent need to develop evidence-based and internationally comparable indicators to help improve patient care and safety worldwide.

WOCN Society Position Paper: Avoidable Versus Unavoidable Pressure Ulcers/Injuries

The issue of whether pressure injuries are avoidable or preventable has been and continues to be an issue of great debate and discussion for many years, and it has significant legal and regulatory implications related to prevention of wounds due to pressure. The following position paper outlines the position of the Wound, Ostomy and Continence Nurses Society (WOCN) on avoidable versus unavoidable pressure injuries. It includes the following information: statement of position, purpose/rationale for the position, definitions of avoidable versus unavoidable pressure injuries, alternative definitions, historical overview, supportive statements from expert opinion and research in the literature, and recommendations for research.

Technical rationality and the decentring of patients and care delivery: A critique of 'unavoidable' in the context of patient harm

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical forms of rationality, has seen the word 'unavoidable' used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken-for-granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care.