Pressure injury identification, measurement, coding, and reporting: Key challenges and opportunities

A national cross-sectional study on the knowledge and attitude of nurses towards prevention of pressure injury and their relationship with its prevalence

BACKGROUND

Pressure injuries can greatly affect a patient's health, safety, and quality of life. The knowledge and attitudes of nurses towards preventing pressure injuries are vital for providing safe, high-quality healthcare. Nursing in Kuwait suffers from a research gap on this topic.

METHODS

This was a cross-sectional study conducted in the public general hospitals of Kuwait to assess nurses' knowledge and attitudes and to measure the point prevalence of pressure injuries and prevention measures. An online form, a Modified Pieper's Pressure Ulcer Knowledge Test and the Moore and Price scale were used to gather data, covering variables related to hospitals, nurses, patients, pressure injuries, and prevention practices. We processed and analysed data using Microsoft Excel and SPSS 23.

RESULTS

The median score of nurses' knowledge on preventing pressure injuries was 73.2% (IQR: 68.3-78.0), and only 31.7% of the knowledge test items were answered correctly by 90% of participants or more. The median attitude score was 41.0 (IQR: 37.0-44.0). There were statistically significant strong positive correlations between nurses' age, years of work experience, attitude score, and the percentage of trained staff complying with measures against pressure injury. Attitude score had a statistically significant and strongly negative correlation with the rate of hospital-acquired pressure injury. The predictors of knowledge score were age, sex, and years since the most recent training was undertaken. Knowledge and a nurse's highest level of education were predictors of attitude scores.

CONCLUSIONS

This study offers inestimable insights into the field. The study's results reveal that nurses' knowledge is unsatisfactory to borderline satisfactory, whereas attitudes are positive. Despite this, the positive attitude is neither reflected in staff compliance with practices aimed at preventing pressure injury nor the rate of hospital-acquired pressure injury. We recommend implementing effective training programmes to bridge these gaps.

CLINICAL TRIAL NUMBER

Not applicable.

Accuracy of Pressure Injury Risk Assessment Tools in Paediatrics: A Systematic Review and Network Meta-Analysis

AIM

To evaluate the accuracy of different pressure injury risk assessment tools in paediatrics and identify risk assessment tools with the best predictive performance.

DESIGN

A systematic review and network meta-analysis.

METHODS

Eight electronic databases, including PubMed, Embase, Web of Science, Cochrane Library, China Knowledge Resource Integrated Database, Weipu Database, Wanfang Database and Chinese Biomedical Database were comprehensively searched. The study was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines 2020. Two researchers independently conducted article screening, data extraction and quality assessment. Statistical analysis was performed using R 4.3.1 and Stata 14.0.

RESULTS

A total of 20 articles were included in this study, involving 4908 patients and 13 pressure injury risk assessment tools for children, of which 15 articles were included in the network meta-analysis. The results showed that the Paediatric Pressure Ulcer Prediction and Evaluation Tool (PPUPET) had the highest superiority index, with the relative sensitivity (0.7, 95% confidence interval, CI: 0.0-1.5) and the relative specificity (1.4, 95% CI: 0.7-1.8). The next was Braden-Q combined with the Glamorgan scale, with a superiority index of 7.08, a relative sensitivity of 1.1 (95% CI: 0.5-1.5) and a relative specificity of 1.3 (95% CI: 0.8-1.7).

CONCLUSIONS

This study suggested that the PPUPET can comprehensively evaluate medical device-related pressure injuries in children, the Braden-Q scale had a better predictive performance for children aged 21 days-8 years in general paediatric departments, and the Glamorgan scale was suitable in the Paediatric Intensive Care Unit.

RELEVANCE TO CLINICAL PRACTICE

This review highlights that clinical practitioners should select appropriate assessment tools based on different departments and the age of children to accurately assess the risk of pressure injuries in children.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

PROTOCOL REGISTRATION

PROSPERO CRD42023470769. http://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study

AIM

To assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement.

DESIGN

Interrater agreement study.

METHODS

Data were collected from November 2019 to December 2022. Paired nurse-assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence-adjusted and bias-adjusted kappa.

RESULTS

Ninety-four nurse assessors participated. Absolute agreement of not-at-risk versus at-risk-any-level was substantial, but absolute agreement of risk-level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower-risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher-risk patients.

CONCLUSION

There were clear differences in pressure injury risk-level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation.

IMPACT

The results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool.

REPORTING METHOD

This study adhered to the GRRAS reporting guideline.

PATIENT/PUBLIC CONTRIBUTION

No patient or public involvement in this study.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Educators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.

Incidence of hospital-acquired pressure injuries and predictors of severity in a paediatric hospital

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays, and higher healthcare costs. Paediatric patients face unique risks, but evidence remains scarce. This study aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital.

METHODS

This retrospective cohort study investigated all paediatric patients between January 2020 and December 2021 using a census approach. Demographic and clinical data including HAPI-related data were accessed from the incident monitoring and hospital administration databases. The incidence rate (per 1000 patient admissions) was calculated based on all admissions. Predictors of HAPI severity were identified using multivariable multinomial logistic regression. The study adhered to the STROBE guidelines for retrospective cohort studies.

RESULTS

The HAPI incidence rate was 6.96 per 1000 patient admissions. Of the age groups, neonates had the highest HAPI incidence (15.5 per 1000 admissions). Critically ill children had the highest rate for admission location (12.8 per 1000 patient admissions). Most reported cases were stage I (64.2%). Age was associated with injury severity, with older paediatric patients more likely to develop higher-stage HAPIs. Additionally, Aboriginal and/or Torres Strait Islander patients had a higher HAPI severity risk.

CONCLUSION

HAPI injuries in paediatric patients are unacceptably high. Prevention should be prioritized, and the quality of care improved in Australia and beyond. Further research is needed to develop targeted prevention strategies for these vulnerable populations.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This research emphasizes the need for standardized reporting, culturally sensitive care and tailored prevention strategies.

IMPACT

The research has the potential to influence healthcare policies and practices, ultimately enhancing the quality of patient care.

REPORTING METHOD

STROBE guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to the conduct of this study.

The value of epidemiological data for pressure ulcer/injury management

Pressure ulcers/injuries (PU/Is) are a burden on healthcare systems worldwide. They are costly and have a negative impact on the quality of life of patients. PU/Is cause discomfort, prolong hospital stays and can even lead to death. Data on the incidence and prevalence of PU/Is are used to implement effective, tailored prevention practices. The aim of this paper is to highlight the importance and value of collecting epidemiological data in terms of its practical use in Slovakia. The prevalence of PU/Is was found to be low compared to global data. Shortcomings in the collection of epidemiological data are highlighted; however, the use of those available data in amending national standards, such as the mandatory reporting of PU/Is, is summarised. Several steps and activities related to the prevention and care of PU/Is have been carried out in Slovakia. It is important to know not only the prevalence in terms of field of care, time and provider, but also, more specifically, the risk characteristics and/or presence of PU/I in order to initiate more individualised and tailored patient care.

Influence of severity of illnesses on risk of death in intensive care unit patients with severity of pressure injuries as mediating variable

This study was to verify whether the severity of pressure injuries (PIs) in intensive care unit (ICU) patients plays a mediating role in the relationship between severity of their illnesses and risk of death. I examined adult patients admitted to the ICUs between 1 January 2014 and 31 August 2021. The average follow-up period was 11.34 months. A total of 390 ICU patients suffered from PIs. The influences of the APACHE II score of the ICU patients on the mediating variable 'unstageable & DTPIs vs. Stage 1&2 PIs' and on risk of death were significant. After controlling the influence of APACHE II score on risk of death, the influences of mediating variables 'Stage 3&4 PIs vs. Stage 1&2 PIs' and 'unstageable & DTPIs vs. Stage 1&2 PIs' on risk of death were also significant. The regression coefficient of APACHE II score of the ICU patients declined after the severity of PIs was included. The Sobel test on the indirect effects also reached the level of significance. The severity of illnesses is a factor that is beyond my control, severe PIs should still be prevented to lower the risk of death.

Enhancing Pressure Injury Surveillance Using Natural Language Processing

OBJECTIVE

This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events.

METHODS

We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets.

RESULTS

Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days.

CONCLUSIONS

Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.

Prevalence of pressure injury on the medical wards of public general hospitals in Kuwait: a national cross-sectional study

BACKGROUND

Pressure injury is a severe problem that can significantly impact a patient's health, quality of life, and healthcare expenses. The prevalence of pressure injuries is a widely used clinical indicator of patient safety and quality of care. This study aims to address the research gap that exists on this topic in Kuwait by investigating the prevalence of pressure injuries and preventive measures on the medical wards of the country's public general hospitals.

METHODS

A cross-sectional research design was adopted to measure the point prevalence of pressure injuries on 54 medical wards in the public general hospitals. Data, including variables pertaining to hospitals, patients, pressure injuries and preventive practices, were collected using an online form. The data were processed and analysed using Microsoft Excel and SPSS 23 (α level = 0.05). Analysis provided an overview of patient, pressure injury characteristics and preventive measures, and the relationships between the patient and pressure injury characteristics and the prevalence of pressure injuries. A model for predicting the determinants of pressure injury prevalence was constructed from a linear regression analysis.

RESULTS

The mean national prevalence of pressure injury was 17.6% (95% CI: 11.3-23.8). Purely community-acquired pressure injuries represent the majority of pressure injuries nationally (58.1%). Regarding preventive measures, "pressure injury assessment on admission" has been provided to 65.5% of patients. Correlation analysis revealed that the only statistically significant correlation with the prevalence of hospital-acquired pressure injury was "pressure injury assessment on admission", which was strongly negative (ρ = -0.857). Therefore, this was the only variable included in the regression analysis as a predictor of pressure injury prevalence (Beta = 0.839). The results showed many statistically significant differences between hospitals with respect to the variables studied.

CONCLUSIONS

The national pressure injury prevalence is high compared to the global rate. The higher percentage of purely community-acquired pressure injuries requires particular attention. Many risk factors for the development of pressure injuries are public health concerns, and effective mitigating strategies are needed. Further research is required to assess the knowledge, attitude, and behaviour of nurses with respect to pressure injuries, and to evaluate preventive and management practices.

Content Validation of an Emergency Department Skin Risk Assessment Instrument

Pressure injuries (PIs) are an important quality and patient safety metric for health care organizations. PI monitoring and treatment are often overlooked in the emergency department (ED). Emergency care professionals must be proactive about PI early identification and prevention strategies. A team at a Level 1 trauma center recognized the need for ED-friendly documentation and a validated ED skin risk assessment instrument. The Bjorklund 25-item ED Skin/Risk Assessment Tool was selected. However, because the tool was not fully validated, permission to validate/use was obtained from the author. The purpose of this research study was to determine the content validity of the Bjorklund Tool. Using a prospective survey design, content experts were recruited from wound, quality, and ED and participated in two rounds of content validation. The experts reviewed the Tool for relevance, clarity, and appropriateness for the ED population. Item-level content validity index (I-CVI) and scale-level CVI (S-CVI) were calculated, with 0.78 and 0.90 as the lower limits of acceptability for individual items and the overall scale, respectively. Of the first round I-CVI ratings, 24 of 75 were below 0.78, including 14 for relevance, four for clarity, and six for appropriateness. S-CVI was 0.7574 for relevance, 0.8809 for clarity, 0.8592 for appropriateness, and 0.8325 overall. The Bjorklund Tool was determined to be invalid in its current form. A novel tool was thus created in the second round per content experts' recommendations. After redesign and simplifying items and images, all I-CVIs rated above 0.78. S-CVI was 0.923 for relevance, 0.9743 for clarity, 0.9615 for appropriateness, and 0.9529 overall. These CVIs indicate excellent content validity of the new UCHealth ED Skin Risk Assessment Instrument. This research contributes to establishment of content validity of a skin risk assessment instrument which can be used in the unique ED setting.

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.

Incidence and characteristics of hospital-acquired mucous membrane pressure injury: A five-year analysis

BACKGROUND

Pressure injuries on mucous membranes are caused by pressure from medical devices at the site of injury and differ to those on the skin. Intensive care patients, who have multiple devices in situ, are particularly vulnerable. There is a significant knowledge gap regarding mucous membrane pressure injury (MMPI) incidence in acute hospital settings.

AIM

To analyse MMPI incidence and characteristics in a tertiary acute general hospital.

METHODS

A secondary data analysis of hospital clinical incident reports was conducted. The sample included all adults with MMPIs between 2015 and 2019. The STROBE reporting guideline was followed.

RESULTS

There were 414 reports of MMPI. Most (91.5%, n = 379) were hospital-acquired with the majority found in intensive care patients (74.4%, n = 282). Hospital-acquired MMPI incidence was 0.1% (11 MMPI per 10,000 hospital episodes). In intensive care, the incidence was 2.4% (235 MMPI per 10,000 intensive care episodes). The median time from device insertion until reporting of an MMPI was 3 days. The most common sites of mucosal injury were the lips (35.6%) and mouth (28.8%). In all cases except one, MMPI was associated with medical device use at the site of injury. Five device types were identified (oral endotracheal tube-related 70.3%; urinary catheter 15.5%; gastric tube 8.3%; nasal prongs 3.5%; tracheostomy tube 2.4%). In intensive care, oral endotracheal tube-related devices were most often associated with MMPI (84.8%), whereas in non-intensive care MMPI it was the urinary catheter (51.4%).

CONCLUSIONS

While hospital-acquired MMPI incidence is relatively low, it is considerably higher in intensive care patients compared to those in non-intensive care settings. The most common sites are the lips and mouth.

RELEVANCE TO CLINICAL PRACTICE

Mucous membrane pressure injuries represent a significant proportion of all hospital-acquired pressure injuries.

PATIENT OR PUBLIC CONTRIBUTION

Neither patients nor the public were directly involved in this project.

Piezoelectric Hydrogel for Prophylaxis and Early Treatment of Pressure Injuries/Pressure Ulcers

Pressure injuries/pressure ulcers (PIs/PUs) are a critical global healthcare issue and represent a considerable burden on healthcare resources. Prevention of PIs/PUs is the least costly approach and minimizes the patient suffering compared with treatment. Besides, sustained tissue load alleviation and microenvironment management are the most crucial properties for dressings in PI/PU prevention. Hydrogel dressings have attracted a lot of attention to prevent PIs/PUs because of their unique mechanical properties and ability to manage the microenvironment of skin. However, auxiliary prophylaxis and early treatment of PIs/PUs remain a challenge and an acute clinical demand. Here, we report on an electroactive hydrogel with large stretchability (∼380%) and skinlike ductility, and Young's modulus (0.48 ± 0.03 MPa) matches that of human skin (0.5-1.95 MPa). The hydrogel displayed piezoelectric properties and mechanical-electric response stability and sensitivity. Our results indicated that the hydrogel was able to promote in vitro angiogenesis under piezoelectric stimulation and exhibited biocompatibility, which has the potential for forming fine vessels at the damaged sites of PIs/PUs. Furthermore, finite element analysis and pressure dispersion experiments demonstrated that the hydrogel was suitable for preventing PIs/PUs by redistributing force, reducing tissue distortion, and maintaining the microenvironment for skin. This work offers a new strategy for designing and evaluating the dressing for prophylaxis and the early treatment of PIs/PUs.

Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.

Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review

BACKGROUND

Whilst performing a pressure injury risk assessment is not in itself preventive, risk status identification is critical to inform the judicious implementation of prevention strategies. Risk assessment is mostly undertaken using a structured tool informed by clinical judgement, though there is a perception that use of clinical judgement alone may be sufficient.

OBJECTIVES

Within acute hospital settings, to identify differences in outcomes (risk status, preventive interventions) following nursing assessment of pressure injury risk when using a structured assessment tool compared to clinical judgement.

DESIGN

Systematic review.

DATA SOURCES

EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus, Web of Science, Ovid EMBASE.

METHODS

Primary research relevant to the objectives was eligible for inclusion. Databases were searched in February 2021 (limits: date 2010-2020, English language, adults). Two reviewers undertook the review process, with a third as arbitrator. Appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Included studies are synthesised narratively. Reporting is in accordance with the PRISMA Statement.

RESULTS

Five moderate to high-quality studies were included. Synthesis was limited by heterogeneity. Several risk assessment tools and methods of clinical judgement were used. Three studies reported pressure injury risk status using both assessment approaches, but in only one did nurses undertake both. Risk status, as identified by each method, varied and was sometimes contradictory. Three studies reported some elements of preventive intervention prescription and/or implementation following risk assessment, but comparison between approaches was limited.

CONCLUSIONS

Some research suggests that risk status varies across different methods of pressure injury risk assessment, but it is unclear what impact this has on preventive intervention use. Risk status was not well linked to preventive interventions. Research is warranted to examine the influence that each approach to risk assessment alone and combined has on identified risk and preventive intervention prescription and implementation.

REGISTRATION

A protocol was prospectively registered with PROSPERO (CRD42021224747).

Pressure Injury Surveillance and Prevention in Australia: Monash Partners Capacity Building Framework

A hospital-acquired pressure injury (HAPI) is a common complication across the globe. The severity of HAPI ranges from skin redness and no skin breakdown to full skin and tissue loss, exposing the tendons and bones. HAPI can significantly impact the quality of life. In addition to the human cost, this injury carries a high economic burden with the cost of treatment far outweighing the preventative measures. The HAPI rates are a key indicator of health services performance. Globally, healthcare services aim to reduce its incidence. In Australia, the federal health minister has prioritised the need for improvement in HAPI surveillance and prevention. Capacity building is vital to optimise pressure injury (PI) surveillance and prevention in acute care services. In this perspective article, we provide a framework for capacity building to optimise HAPI prevention and surveillance in a large cross-sector collaborative partnership in Australia. This framework comprises six key action areas in capacity building to optimise the HAPI outcomes, such as research, organisational development, workforce development, leadership, collaboration, and consumer involvement.

Pressure Injury Prevention in COVID-19 Patients With Acute Respiratory Distress Syndrome

Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019 and became a pandemic in a short period of time. While most infected people might have mild symptoms, older people and people with chronic illnesses may develop acute respiratory distress syndrome (ARDS). Patients with ARDS with worsening hypoxemia require prone positioning to improve the respiratory mechanics and oxygenation. Intubated patients may stay in a prone position up to 12–16 h, increasing the risk of pressure injury (PI). Frequent skin inspections and PI risk assessment in COVID-19 patients will be challenging due to hospital infection control measures aimed to reduce the risk for health professionals. In this perspective article, we summarize the best practice recommendations for prevention of PI in SARS-CoV-2-infected ARDS patients in prone positioning. Prior to positioning patients in prone position, the main recommendations are to (1) conduct a skin assessment, (2) use pressure redistribution devices, (3) select an appropriate mattress or an overlay, (4) ensure that the endotracheal tube securing device is removed and the endotracheal tube is secured with tapes, (5) use a liquid film-forming protective dressing, and (6) lubricate the eyes and tape them closed. Once a patient is in prone position, it is recommended to (1) use the swimmer's position, (2) reposition the patient every 2 h, and (3) keep the skin clean. When the patient is repositioned to supine position, healthcare professionals are advised to (1) assess the pressure points and (2) promote early mobilization.

Ultrasound assessment of deep tissue on the wound bed and periwound skin: A classification system using ultrasound images

AIMS

Given the utility of ultrasonography in assessing pressure injury, some ultrasonographic findings have already been used as indicators of deep tissue pressure injury. Despite reports showing that a cloud-like ultrasonographic pattern reflected the presence of deep tissue necrosis, identifying cloud-like patterns was difficult given the presence of similar findings, such as a cobblestone-like pattern. This case series reports patients with pressure injuries who presented with a cloud-like (five cases) and cobblestone-like (four cases) pattern during ultrasonography.

METHODS

This study was conducted at a Japanese university hospital. Participants included patients who underwent routine examination by an interdisciplinary pressure injury team. Pressure injury severity was assessed using the DESIGN-R® scoring system and the wound size were measured using ImageJ software based on the wound photograph.

RESULTS

Among the five cases showing a cloud-like pattern upon ultrasonography, all exhibited an increase in the total DESIGN-R® score, while three exhibited an increase in wound size. On the other hand, all four cases showing a cobblestone-like pattern displayed no increase in the total DESIGN-R® score and a decrease in wound size.

CONCLUSION

This study suggested that distinguishing between cloud-like and cobblestone-like ultrasonography patterns is necessary for determining the presence or absence of deep tissue pressure injury. In order to comprehensively assess pressure injuries with ultrasonography, future studies should be conducted in a large number of participants.

Pressure injury data in Australian acute care settings: A comparison of three data sets

Hospital-acquired pressure injuries (HAPIs) represent a serious clinical and economic problem. The cost of treating HAPIs in Australian public hospitals was recently reported at AUS$983 million per annum. There are three main sources of data for documenting pressure injury (PI) occurrence in Australian hospitals: incident reporting, medical record coded data, and real-time surveys of pressure injury. PI data reported at hospital level and to external agencies using these three different sources are variable. This reporting issue leads to inaccurate data interpretation and hinders improvement in accuracy of PI identification and PI prevention. This study involved a comparison of the three different data sources in selected Australian hospitals, to improve the accuracy and comparability of data. Findings from this study provide benchmark areas for improvement in PI documenting and reporting. Better understanding the agreement between the three data sets could lead to a more efficient and effective sharing of data sources.

Patient education materials on pressure injury prevention in hospitals and health services in Victoria, Australia: Availability and content analysis

Pressure injuries (PIs) are a common quality indicator for hospital care, and preventing PIs often requires patient engagement; as such, Australian consensus research has recommended that high-quality education materials be made to patients for PIs via hospital networks. The purpose of the present study was to assess the availability and accuracy of patient education materials on PIs in publicly available hospital websites in Victoria, Australia. Two independent coders assessed 212 websites for content on PI prevention and management, analysing availability and accuracy of PI definitions, risk factors, preventive strategies, referral, visual tools, consumer endorsement, information for family/carers, and translation on community languages. A greater proportion of hospitals did not have any patient education materials on PI prevention publicly available, with private hospitals (compared with public) and metropolitan hospitals (compared to rural) more likely to have materials available on their sites. The available materials contained accurate messages on PI defining characteristics and risk factors for PIs, although there was considerable variability on the availability of other information. Our findings suggest a significant deficit in the availability of educational materials for acute care patients and their families. There is a need for evidence-based, consumer-endorsed, uniform materials on all hospital websites to prevent PIs in acute care.

Selection of Appropriate Wound Dressing for Various Wounds

There are many factors involved in wound healing, and the healing process is not static. The therapeutic effect of modern wound dressings in the clinical management of wounds is documented. However, there are few reports regarding the reasonable selection of dressings for certain types of wounds in the clinic. In this article, we retrospect the history of wound dressing development and the classification of modern wound dressings. In addition, the pros and cons of mainstream modern wound dressings for the healing of different wounds, such as diabetic foot ulcers, pressure ulcers, burns and scalds, and chronic leg ulcers, as well as the physiological mechanisms involved in wound healing are summarized. This article provides a clinical guideline for selecting suitable wound dressings according to the types of wounds.

First-Line Interactive Wound Dressing Update: A Comprehensive Review of the Evidence

Wound management is a significant and growing issue worldwide. Knowledge of dressing products and clinical expertise in dressing selection are two major components in holistic wound management to ensure evidence-based wound care. With expanding global market of dressing products, there is need to update clinician knowledge of dressing properties in wound care. Optimal wound management depends on accurate patient assessment, wound diagnosis, clinicians’ knowledge of the wound healing process and properties of wound dressings. We conducted a comprehensive review of the physical properties of wound dressing products, including the advantages and disadvantages, indications and contraindications and effectiveness of first-line interactive/bioactive dressing groups commonly used in clinical practice. These include semipermeable films, foams, hydroactives, alginates, hydrofibers, hydrocolloids, and hydrogels. In making decisions regarding dressing product selection, clinicians need to ensure a holistic assessment of patient and wound etiology, and understand dressing properties when making clinical decisions using wound management guidelines to ensure optimal patient outcomes. This review has highlighted there is lack of high quality evidence and the need for future well designed trials.

Prevalence of pressure injury in adults presenting to the emergency department by ambulance

INTRODUCTION

Pressure injuries are harmful, painful, and potentially preventable. Although hospital-acquired pressure injury prevalence is decreasing, it is unclear if some pressure injuries develop before hospital admission. The objective of this study was to investigate the prevalence of pressure injury in adults on arrival by ambulance to the emergency department (ED).

METHODS

An observational, cross-sectional descriptive study design was used. Participants (n = 212) were recruited from the EDs of two Australian tertiary hospitals. Full skin inspection and pressure injury risk assessment, using Braden and Waterlow scores, were undertaken within 1 h of presentation.

RESULTS

Pressure injuries were identified in 11 of 212 participants, giving a prevalence of 5.2% at presentation. Nearly all were admitted to hospital, giving a prevalence of 7.8% at this entry point. Participants with pressure injury and those at high risk of injury were found to have spent longer in the ambulance and within the ED. During ambulance transport and in the first hour of presentation to the ED, it was rare that pressure-relieving interventions were implemented, even for those with an identified pressure injury and those at high risk.

CONCLUSIONS

The results indicate that early pressure injury surveillance and risk assessment are merited at the point of presentation to the ED, so that prevention and treatment can be implemented at the earliest possible opportunity. Although it is more challenging to manage pressure injuries within the ambulance and ED, the use of pressure-relieving devices should be considered for those at greatest risk. Further research is recommended.

Pressure injury identification, measurement, coding, and reporting: Key challenges and opportunities

Pressure injury (PI) rates are a commonly used indicator of performance of health care facilities, both in acute and subacute settings. However, measuring PI rates in an accurate and reproducible fashion has been challenging. The consequences of poor measurement may include failure to identify poorly performing institutions or incorrect accusations of poor quality care. In this article, we describe the main challenges in identification, coding, and reporting of PIs. Issues include inconsistent identification of PIs at the time of admission, variations in the intensity of PI detection, and differing approaches to coding and the adjustment for differing risks amongst different patient population. These are compounded by differences in the epidemiological approach because rates will differ according to whether patients are surveyed cross-sectionally (eg, on a set day per month) or if the survey is undertaken at discharge. In some cases, financial incentives may also influence PI reporting. We also discuss potential strategies for improving data collection and benchmarking as an aid to reducing PI prevalence.