Pressure injury prevalence and incidence in acute inpatient care and related risk factors: A cross-sectional national study

Perioperative Risk Factors of Postoperative Pressure Injuries in Patients after Surgical Hematoma Evacuation of Intracranial Hemorrhage: A Retrospective Cohort Study

OBJECTIVE

To identify the incidence and perioperative risk factors of postoperative pressure injuries (PIs) in patients with intracranial hemorrhage who had surgical evacuation of hematoma.

METHODS

This retrospective cohort study was conducted at a tertiary care university hospital. Researchers collected medical record data from April 2010 to March 2020 and conducted backward selection in multiple logistic regression.

RESULTS

Of the 386 patients identified, 103 (26.7%) developed postoperative PIs. The most common site of PI was the coccyx (n = 56; 38.9%). More than half of the patients had stage 2 PIs, and 43 (41.7%) developed PIs 14 or more days after surgery. Three variables were associated with an increased risk of postoperative PI: older age (P = .025), receiving a packed red blood cell transfusion while in the ICU (P = .004), and staying in the ICU for more than 7 days (P < .001).

CONCLUSIONS

The present findings indicate that risk factors for postoperative PIs include older age, requiring a blood transfusion, and longer ICU stays, which may increase nursing workload regardless of surgery type. Future research on postoperative PIs in patients undergoing neurosurgery should consider additional ICU work environment factors, including nurse-to-patient ratio and immobility-related factors such as duration of medical device use. Further, international comparisons of risk factors for postoperative PIs among patients undergoing neurosurgery are needed.

National improvements in falls and pressure injuries in Swiss hospitals from 2011 to 2022: A secondary data analysis of national quality monitoring data

INTRODUCTION

National quality monitoring in healthcare and, in particular, the (transparent) comparison of results can trigger improvements at the structural and procedural levels and, thus, improve the outcome. In Switzerland, this kind of monitoring was conducted between 2011 and 2022 (except 2020 and 2021 due to the COVID-19 pandemic) for falls and pressure injuries in the hospital setting. The aim of this study was to examine the improvements in the quality of care for falls and pressure injuries in Swiss hospitals during the monitoring period.

METHOD

A secondary data analysis was conducted of the Swiss national quality monitoring data on falls and pressure injuries based on a multicenter cross-sectional design. Descriptive data analysis was performed.

RESULTS

The hospital-acquired pressure injury prevalence rate varied between 3.6% and 5.8%, and the in-hospital fall rate was between 3.0% and 4.6%. The prevalence rates showed their greatest decrease after the first monitoring, with only a slight decrease/stagnation observed thereafter. An increase in prevalence rates was revealed after the two-year monitoring break due to the COVID-19 pandemic. The structural conditions improved (e.g., implementation of guidelines) and more processes were implemented at the patient level (e.g., use of preventive measures) over the monitoring period. At the same time, patients tended to be older, more multimorbid, and more at risk of pressure injuries.

CONCLUSION

Considering the change in the patient population (higher risk) and the findings on the structure and process indicators, the improvement in quality of care is likely to be more pronounced than the prevalence rates suggest.

Impact of the End PJ Paralysis interventions on patient health outcomes at the participating hospitals in Alberta, Canada

PURPOSE

Multiple hospitals in Alberta implemented the End PJ Paralysis - a multicomponent inpatient ambulation initiative aimed at preventing the adverse physical and psychological effects patients experience due to low mobility during admission. To inform a scale-up strategy, this study assessed the impact of the initiative based on select process and outcome measures.

MATERIALS AND METHODS

Clinical and administrative data were obtained from the hospital Discharge Abstract Database, Research Electronic Data Capture (Redcaps), and Reporting and Learning System for Patient Safety. The variables explored were length of stay, inpatient falls, discharge disposition, pressure injury, patient ambulation, and patient dressed rates. We then used the Interrupted Time Series design for impact analysis.

RESULTS

The analysis included discharge abstracts for 32,884 patients and the results showed significant improvements in outcomes at the participating units. The length of stay and inpatient falls were reduced immediately by 1.8 days (B2=-1.80, p = 0.044, 95% CI [-3.54, -0.05]), and 2.2 events (B2=-2.22, p = 005, 95% CI [-3.75, -0.69]). The percentage of patients discharged home increased overtime (B2=.39, p=.006, 95% CI [.11, .66]). Mobilization and dressed rates also improved.

CONCLUSIONS

The findings imply the interventions safely mitigated the risk of immobility-induced complications, including deconditioning and hospital-acquired disability.

Community-Acquired Pressure Injuries: Prevalence, Risk Factors and Effect of Care Bundles-An Integrative Review

AIM AND OBJECTIVES

To summarise the evidence and present the state of the science on pressure injury care bundles in the community. Specifically, this review examined (i) the extent of pressure injury by studying its prevalence and incidence in the last 10 years, (ii) the risk factors associated with community-acquired pressure injury and (iii) the components and outcomes associated with effective pressure injury care bundles in the community.

BACKGROUND

PI care bundles have effectively reduced PI rates; however, there is limited evidence of care bundles used in community settings.

DESIGN

Integrative review.

METHODS

This integrative review is guided by the Whittemore and Knafl framework and follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Quality appraisal was applied to assess the quality of selected articles. Data relevant to the review aims were extracted, and findings were synthesised and presented. PubMed, Medline, CINAHL and Web of Science were searched. Studies published in the English language between 2012 and 2022 were retrieved.

RESULTS

A total of 89 articles were retrieved; 25 met the inclusion criteria. Most studies reported the point prevalence and period prevalence of community-acquired pressure injuries, and only one study reported the incidence of community-acquired pressure injuries. The point prevalence and period prevalence of community-acquired pressure injury were 0.02% to 10.8% and 2.7% to 86.4%, respectively, and the cumulative incidence was 1.3%. The risk factors for community-acquired pressure injury assessed vary between studies; older age, poor nutrition, immobility and multiple comorbidities are commonly reported. Socioeconomic and caregiving factors were not studied. Very few studies evaluated pressure injury care bundles in the community. Even so, the components of the pressure injury care bundle vary between studies.

CONCLUSIONS

Pressure injury development is associated with a complex interplay of factors. Socioeconomic and caregiving factors were not examined in any of the papers. There is a lack of understanding of the components and outcomes associated with effective pressure injury care bundles in the community.

RELEVANCE TO CLINICAL PRACTICE

Despite their prevalence, community-acquired pressure injuries (CAPIs) are often underreported due to inadequate follow-up and reporting mechanisms. Although the risk factors for CAPIs vary across studies, older age, impaired mobility, multiple comorbidities and malnutrition consistently emerge as key contributors. Pressure injury preventive care bundles are more commonly used in the acute care setting rather than the community setting.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Effect of the "aSSKINg" Model in Reducing Pressure Ulcer Risk: A Comparative Study Using the Braden Risk Assessment Score

Pressure ulcer is considered a common and costly problem in the care of patients. Prevention and management of pressure ulcer are very important due to the high cost of treatment and the adverse consequences of pressure ulcer. This study aimed to evaluate the effect of implementing "aSSKINg" model in reducing pressure ulcer risk. This study used a before- and after-intervention quasi-experimental design. This study was performed on 60 patients who were not randomly selected and assigned in to control and study group. The data collection tool was a 3-part sheet (Braden scale, skin health assessment, and Pressure ulcer assessment). The incidence of pressure ulcer was 19 (60.0%) in the control group versus 9 (30.0%) in the study group with statistical significant differences. The most common site of pressure ulcer was coccyx (6 [31.6%]) in the control group and Heel (3 [33.3%]) in the study group. The application of "aSSKINg" model in the patients with pressure ulcers is effective in reducing the incidence and severity of pressure ulcers.

Point prevalence and risk factors for pressure ulcers in hospitalized adult patients: a cross-sectional study

OBJECTIVE

To estimate the point prevalence of and risk factors associated with the development of pressure ulcers at a university hospital in Brazil.

METHODS

This study was conducted on 196 participants using a structured questionnaire, physical examination of the skin, and the Braden scale. The Mann-Whitney U, χ2, or Fisher's exact tests were used to compare the participants and the associations of variables with pressure ulcers. A modified multivariate Poisson regression model was built considering the presence of pressure injuries and the independent variables.

RESULTS

The point prevalence of pressure ulcers was 10.71% and was significantly associated with less than 12 years of schooling (p=0.0213), use of antihypertensive drugs during hospital stay (p=0.0259), diagnosis of systemic hypertension (p=0.0035), and diabetes mellitus. Lower scores on the Braden scale (p=0.0001) were positively associated with the presence of pressure ulcers. Furthermore, cardiovascular disease (p=0.0267) and diaper use (p=0.0001) were associated with the presence of pressure ulcers. Moreover, they were also associated with prolonged hospital stay, advanced age, less than 12 years of schooling, use of antihypertensive drugs, hypertension, diabetes, and lower Braden scale scores.

CONCLUSION

Health professionals should be aware of the risk factors associated with pressure ulcers, evaluate patient skin daily, and offer prevention. Our findings support the need to allocate resources for the prevention and treatment of pressure injuries.

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.

The prediction model for intraoperatively acquired pressure injuries in orthopedics based on the new risk factors: a real-world prospective observational, cross-sectional study

Introduction: Orthopedic patients are at high risk for intraoperatively acquired pressure injuries (IAPI), which cause a serious issue and lead to high-expense burden in patient care. However, there are currently no clinically available scales or models to assess IAPI associated with orthopedic surgery. Methods: In this real-world, prospective observational, cross-sectional study, we identified pressure injuries (PI)-related risk factors using a systematic review approach and clinical practice experience. We then prepared a real-world cohort to identify and confirm risk factors using multiple modalities. We successfully identified new risk factors while constructing a predictive model for PI in orthopedic surgery. Results: We included 28 orthopedic intraoperative PI risk factors from previous studies and clinical practice. A total of 422 real-world cases were also included, and three independent risk factors-preoperative limb activity, intraoperative wetting of the compressed tissue, and duration of surgery-were successfully identified using chi-squared tests and logistic regression. Finally, the three independent risk factors were successfully used to construct a nomogram clinical prediction model with good predictive validity (area under the ROC curve = 0.77), which is expected to benefit clinical patients. Conclusion: In conclusion, we successfully identified new independent risk factors for IAPI-related injury in orthopedic patients and developed a clinical prediction model to serve as an important complement to existing scales and provide additional benefits to patients. Our study also suggests that a single measure is not sufficient for the prevention of IAPI in orthopedic surgery patients and that a combination of measures may be required for the effective prevention of IAPI.

Nursing interventions in preventing pressure injuries in acute inpatient care: a cross-sectional national study

BACKGROUND

Several nursing interventions for pressure injury prevention have been identified, including risk and skin status assessment. The aim of this study was to explore prevention of pressure injuries in Finnish acute inpatient care. The data were collected on pressure injury risk and skin status assessments, repositioning, the use of support surfaces, preventive skin care, malnutrition risk assessment, and nutritional care.

METHODS

This multicentre, cross-sectional study was conducted in 16 acute care hospitals, excluding psychiatric care. Adult patients from inpatient care were recruited on the annual international Stop Pressure Ulcers Day in 2018 and 2019. Enrolment covered 6,160 participants in 503 units. Descriptive statistics were used to describe pressure injuries, risk assessments, and preventive nursing interventions. Cross tabulation, Pearson's chi-square and Fisher's exact tests were also used. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

In all, 30% of the participants had their pressure injury risk assessed during the care, and for 19% within 8 h after admission. The same time limit in risk assessment was fulfilled for 16% of the participants with a pressure injury, and 22% of the participants using a wheelchair or being bedridden. A skin status assessment within 8 h after admission was conducted for 30% of all participants, and for 29% of the participants with a pre-existing pressure injury, and for 38% of the participants using a wheelchair or being bedridden. The risk of malnutrition was screened in 20% of the participants. Preventive interventions were targeted to participants with a pressure injury instead of patients with a high-pressure injury risk.

CONCLUSION

This study adds evidence about pressure injury risk assessments and the implementation of preventive nursing interventions in Finnish acute care. Skin status and pressure injury risk assessments were irregularly conducted, and the outcome was not used by nurses to guide the implementation of preventive interventions. The results reveal the gaps in evidence-based nursing practice, which require further efforts to prevent pressure injuries. Improving the national focus on pressure injury prevention practice is critical for improving healthcare for our patients.

Pressure injury prevalence and characteristics in patients with COVID-19 admitted to acute inpatient rehabilitation unit

Objective

To investigate the incidence and severity of pressure injuries among COVID-19 patients who required acute hospitalization and subsequent acute inpatient rehabilitation (AIR).

Design

Data was collected retrospectively from medical charts of COVID-19 patients who were admitted to AIR during April 2020-April 2021.

Setting

Acute Inpatient Rehabilitation at a single hospital in the greater New York metropolitan area.

Participants

Subjects included COVID-19 patients (N = 120) who required acute hospitalization and subsequent acute inpatient rehabilitation, of whom 39 (32.5%) had pressure injuries.

Interventions

Not applicable.

Main outcome measures

The incidence, location, and severity of pressure injuries in COVID-19 patients, as well as demographic and clinical characteristics of the acute hospitalization.

Results

Among patients who developed pressure injuries, more patients received mechanical ventilation (59% vs. 33%, P < 0.05) and tracheostomy (67% vs. 17%, P < 0.00001). The lengths of stay were longer in both the intensive care unit (ICU) (34 vs. 15 days, P < 0.005), and in acute inpatient rehabilitation (22 vs. 17 days P < 0.05).

Conclusion

Pressure injuries were more common in COVID-19 patients who had longer lengths of stay, received mechanical ventilation or tracheostomy, during acute hospitalization. This supports the use of protocols to prioritize pressure offloading in this patient population.

Pressure ulcers in hospital patients: incidence and risk factors

OBJECTIVE

With an ageing population and a rising number of people with chronic conditions and disabilities, pressure ulcers (PUs) are a frequent problem. Prevention and treatment, especially targeted at older people, frail and non-self-sufficient patients, are central to care provided by nurses. The objective of this study is to establish the incidence of PUs in hospital inpatients and identify possible associated risk factors.

METHOD

A clinical observational study was conducted from May to November 2019 in a sample of patients admitted to Azienda Sociosanitaria Ligure 2 in Italy. Clinical and sociodemographic data were collected at admission and at discharge, through a questionnaire or collection card. The analysis was done using SAS 9.4 2017 software.

RESULTS

In 7% of the 515 participating patients, PUs occurred during hospitalisation; PUs at stages I and II were predominantly in the coccyx, heels and malleolus.

CONCLUSION

Significant associations were found between the development of lesions and age, certain pathologies, the degree of patient autonomy and the level of skin integrity.

Nationwide time-series surveys of pressure ulcer prevalence in Japan

OBJECTIVE

The Japanese Society of Pressure Ulcers (JSPU) has two purposes: first, to improve knowledge and skills among health professionals related to preventing and managing pressure ulcers (PUs); and second, to represent those in the field managing PUs, including with government and health authorities. Since 2006, JSPU has conducted fact-finding surveys about every four years to identify PU prevalence in Japan (2006, 2010, 2013 and 2016). Based on the prevalence identified by these surveys, an attempt was made to validate the achievements of JSPU's activities.

METHOD

Information from one-day surveys of hospitals, long-term care health facilities, long-term care welfare facilities, and home visit nursing care stations was analysed. We used generalised estimating equations to estimate the proportions of PUs and their 95% confidence intervals (CIs) for each survey.

RESULTS

A total of 662,419 patients in 2631 facilities participated in the surveys. The estimated proportions for all facilities (95% CI) in chronological order, from the first to the fourth survey, were: 2.67% (2.52-2.83); 2.61% (2.43-2.80); 1.99% (1.83-2.17); and 1.79% (1.65-1.94), respectively. In all facility types, the proportion of PUs was lower in the fourth survey than the first survey.

CONCLUSION

The proportion of PUs showed a decreasing trend and was low according to global standards, demonstrating the efficacy of JSPU's activities.

Development and validation of a machine learning algorithm-based risk prediction model of pressure injury in the intensive care unit

The study aimed to establish a machine learning-based scoring nomogram for early recognition of likely pressure injuries in an intensive care unit (ICU) using large-scale clinical data. A retrospective cohort study design was employed to develop and validate a top-performing clinical feature panel accessibly in the electronic medical records (EMRs), which was in the mode of a quantifiable nomogram. Clinical factors regarding demographics, admission cause, clinical laboratory index, medical history and nursing scales were extracted as risk candidates. The performance improvement was based on the application of the machine learning technique, comprising logistic regression, decision tree and random forest algorithm with five-fold cross-validation (CV) technique. The comprehensive assessment of sensitivity, specificity and the area under the receiver operating characteristic curve (AUROC) was considered in the evaluation of predictive performance. The receiver operating characteristic curves revealed the top performance for the logistic regression model in respect to machine learning improvement, achieving the highest sensitivity and AUC among three types of classifiers. Compared against the 23-point Braden scale routinely recorded online, an incorporated nomogram of logistic regression model and Braden scale achieved the best performance with an AUC of 0.87 ± 0.07 and 0.84 ± 0.05 in training and test cohort, respectively. Our findings suggest that the machine learning technique potentiated the limited predictive validity of routinely recorded clinical data on pressure injury development during ICU hospitalisation. Easily accessible electronic records held the potentials to substitute the traditional Braden score in the prediction of pressure injury in intensive care unit. Preoperative prediction of pressure injury facilitates the exemption from the severe consequences.

Validation of the Helsinki University Hospital prevent pressure Injury Risk Assessment Tool: a prospective observational study

Background

Pressure injures are a common adverse event in a hospital, and they are one of the most important quality indicators of patient care. Risk assessment is recommended as the first step in the prevention of pressure injuries. A Prevent Pressure Injury Risk Assessment Tool is a new tool for risk assessment that was developed by the Helsinki University Hospital.

Aim

The aim of this study was to evaluate the predictive validity and the concurrent validity of the Prevent Pressure Injury Risk Assessment Tool in acute care.

Method

The prospective observational study was conducted in 19 in-patient wards representing internal medicine, neurology, and surgery during 2017–2018. The participants’ inclusion criteria were: age ≥18 years old, no pressure injury on admission to the hospital and consenting to participate. The data collected by physical assessment of patients was combined with data from electronic patient records. Each patient was assessed by two different nurses with the Prevent Pressure Injury Risk Assessment Tool and the Braden Scale at patient admission. Furthermore, skin condition was observed throughout the hospital stay.

Results

Of the 637 patients accepted for the study, 10 (1.6%) developed a pressure injury during the hospital stay. Poisson regression analysis showed that pressure injuries were more likely in high–risk patients compared to those with low-risk. The sensitivity of the Prevent Pressure Injury Risk Assessment Tool was adequate (75%), while specificity was poor (40%). A moderate correlation was found between the Prevent Pressure Injury Risk Assessment Tool and the Braden Scale.

Conclusions

The Prevent Pressure Injury Risk Assessment Tool may be useful for identifying the adult pressure injury risk patients in acute care. Further research is needed to evaluate interrater reliability, and usability and validity with different patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00799-6.