Pressure ulcers in older hospitalised patients and its impact on length of stay: a retrospective observational study

Exosomes from miR-21-5p-modified adipose-derived stem cells promote wound healing by regulating M2 macrophage polarization in a rodent model of pressure ulcer

Pressure ulcers represent a significant healthcare burden worldwide. Numerous research has demonstrated the therapeutic potential of adipose-derived stem cell (ADSC)-derived exosomes in promoting wound healing. This study aims to investigate whether exosomes derived from miRNA-modified ADSCs play a role in pressure ulcers by affecting inflammation and macrophage polarization. ADSCs were identified by detecting the surface markers and multilineage differentiation potential. Lentiviruses carrying miR-21-5p were transduced in ADSCs for stable overexpression. Exosomes were extracted from ADSCs and identified. RT-qPCR was employed to detect RNA levels. A mouse model of pressure ulcers was established, followed by injection of exosomes. DiO staining was conducted to assess exosome biodistribution at wound sites. Hematoxylin-eosin and Masson staining were conducted for histological analysis. Immunofluorescence staining was used to evaluate TNF-α and IL-6 expression in mouse wound tissues. Western blotting was conducted to evaluate protein levels of macrophage polarization markers in vivo and in vitro. The results revealed that exosomes derived from miR-21-5p-overexpressing ADSCs promoted wound healing and reduced inflammatory cytokine expression in mouse wound tissues. Moreover, exosomal miR-21-5p induced macrophage M2 polarization in both mouse wound tissues and bone marrow-derived macrophages. Mechanistically, exosomal miR-21-5p inhibited NF-κB signal transduction in mouse wound tissues. In conclusion, ADSC-derived exosomes promote M2 macrophage polarization and inhibit inflammatory response in pressure ulcers via miR-21-5p delivery.

Prevalence of Delayed Discharge Among Patients Admitted to the Internal Medicine Wards: A Cross-Sectional Study

Background/Objectives: Hospital bed shortage is a widespread issue affecting healthcare systems globally, often exacerbated by bed-blocking, a phenomenon where patients remain hospitalized longer than medically necessary due to discharge delays. The aim of this study was to evaluate the prevalence of patients with bed-blocker status admitted to the internal medicine wards. Methods: This cross-sectional study was conducted at an academic tertiary-level hospital in Milan (Italy) from 1 January to 31 December 2023. All adult patients identified as ready for discharge by the bed management service, but whose actual discharge was delayed by more than 24 h, were included. Clinical data were retrieved from electronic medical and nursing records. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results: Out of 2480 admissions to the internal medicine wards, 147 patients (5.9%) experienced delayed discharge. The median hospital length of stay was 22 days (IQR: 15.0-33.0); the median duration of appropriate stay was 6 days (IQR: 2.0-13.0), and the median length of delayed stay was 14 days (IQR: 7.0-21.0). Waiting for transfer to lower-intensity care facilities was the primary cause of delayed discharge. Complications during delayed stays included delirium (31.3%) and hospital-acquired infections (35.4%), particularly urinary tract infections (17.7%). Logistic regression identified older age (≥75 years), extended hospital length of stay, emergency admissions, and discharge to long-term care as independent predictors of bed-blocker status. Conclusions: This study highlights delayed discharges as a significant issue in internal medicine wards, driven by advanced age, caregiver absence, and high dependency in activities of daily living.

Incidence and Risk Factors for Hospital-Acquired Pressure Ulcers in Patients With COVID-19

BACKGROUND

Hospital-acquired pressure ulcers (HAPU) are a major challenge in healthcare settings, especially in vulnerable populations such as patients with COVID-19. The aim of this study is to examine the association of COVID-19 infection with occurrence of HAPU, with the goal of enhancing care protocols and reducing HAPU incidence in at-risk populations.

METHODS

A retrospective analysis was conducted for 8,158 hospitalized patients aged 20 years and older who were treated from April 2022 to March 2023. The study included COVID-19-positive patients and non-COVID-19 patients. Data were collected for age, sex, body mass index, total protein, albumin (ALB), hemoglobin, COVID-19 infection, and independence in activities of daily living (ADL). For patients with COVID-19, surgical history, intensive care unit admission, physical restraints, mechanical ventilation, and prone positioning therapy were also examined. Risk factors for HAPU were evaluated based on these variables.

RESULT

In all 8,158 patients, low ALB and COVID-19 infection were independent risk factors for HAPU. In the COVID-19 cohort (n=412), low independence in ADL was also an independent risk factor. These findings underscore the importance of targeted interventions to mitigate the occurrence of HAPU, particularly for high-risk COVID-19 patients.

CONCLUSION

This study showed that advanced age, low ALB, and COVID-19 infection are significant independent risk factors for HAPU. For COVID-19 patients, isolation policies may have reduced caregiver-patient interactions and hindered the delivery of frequent care, thereby increasing the risk of HAPU, particularly in patients with low ADL independence. For high-risk patients, a multidisciplinary approach is essential, with tailored PU prevention strategies implemented early to address individual needs and reduce the risk of HAPU.

Cost of Illness of Pressure Injuries in the Inpatient Area of a Socio-Health Center in Spain

ABSTRACT

OBJECTIVE

To estimate the increase in length of stay and cost of illness of pressure injuries (PIs) in the inpatient area of a socio-health center.

METHODS

This was a retrospective cohort study that included a consecutive sampling of patients admitted to the inpatient programs of a socio-healthcare center between January 1, 2016, and December 31, 2018. Data were retrospectively extracted from patients' electronic health records.

RESULTS

During the study period 4,062 patients were admitted to the different hospitalization programs. The patients' mean age was 75.34 ± 13.69 years, and 51.2% of them were men. Of these, 1,421 patients had PIs, and 318 patients had to prolong their hospital stay due to PIs. These 318 patients were admitted 12,089 days longer (mean of 38.01 ± 41.49 days per patient) than patients without a PI, representing an expense of €1,381,006 (US $1,430,722). The cost of illness in the period under study was estimated at €1,922,049 (US $1,991,212). The average cost of PI treatment per patient was €1,352.60 ± €3,351.43 (US $1,401.29 ± $3,472.08), and the average cost of treatment until complete resolution of a PI was €2,064.65 ± €4,282.48 (US $1,470.79 ± $4,436.65). The cost of treatment ranged from €1,419.68 ± €3,100.47 (US $2,138.98 ± $3,212.09) for stage 1 PIs to €6,299.31 ± €10,000.57 (US $6,526.08 ± $10,360.59) for stage 4 PIs.

CONCLUSIONS

This study highlights the significant health and economic impacts of PIs in the inpatient area of a socio-health center. The findings emphasize the necessity of effective prevention strategies to mitigate the occurrence of PIs and their associated costs. By understanding the financial burden of PIs, healthcare providers and policymakers can make informed decisions to improve resource allocation, enhance patient care, and reduce financial strain on the healthcare system.

Risk prediction tools for pressure injury occurrence: an umbrella review of systematic reviews reporting model development and validation methods

BACKGROUND

Pressure injuries (PIs) place a substantial burden on healthcare systems worldwide. Risk stratification of those who are at risk of developing PIs allows preventive interventions to be focused on patients who are at the highest risk. The considerable number of risk assessment scales and prediction models available underscores the need for a thorough evaluation of their development, validation, and clinical utility. Our objectives were to identify and describe available risk prediction tools for PI occurrence, their content and the development and validation methods used.

METHODS

The umbrella review was conducted according to Cochrane guidance. MEDLINE, Embase, CINAHL, EPISTEMONIKOS, Google Scholar, and reference lists were searched to identify relevant systematic reviews. The risk of bias was assessed using adapted AMSTAR-2 criteria. Results were described narratively. All included reviews contributed to building a comprehensive list of risk prediction tools.

RESULTS

We identified 32 eligible systematic reviews only seven of which described the development and validation of risk prediction tools for PI. Nineteen reviews assessed the prognostic accuracy of the tools and 11 assessed clinical effectiveness. Of the seven reviews reporting model development and validation, six included only machine learning models. Two reviews included external validations of models, although only one review reported any details on external validation methods or results. This was also the only review to report measures of both discrimination and calibration. Five reviews presented measures of discrimination, such as the area under the curve (AUC), sensitivities, specificities, F1 scores, and G-means. For the four reviews that assessed the risk of bias assessment using the PROBAST tool, all models but one were found to be at high or unclear risk of bias.

CONCLUSIONS

Available tools do not meet current standards for the development or reporting of risk prediction models. The majority of tools have not been externally validated. Standardised and rigorous approaches to risk prediction model development and validation are needed.

TRIAL REGISTRATION

The protocol was registered on the Open Science Framework ( https://osf.io/tepyk ).

Improving machine learning algorithm for risk of early pressure injury prediction in admission patients using probability feature aggregation

Objective

Pressure injuries (PIs) pose a significant concern in hospital care, necessitating early and accurate prediction to mitigate adverse outcomes.

Methods

The proposed approach receives multiple patients records, selects key features of discrete numerical based on their relevance to PIs, and trains a random forest (RF) machine learning (ML) algorithm to build a predictive model. Pairs of significant categorical features with high contributions to the prediction results are grouped, and the PI risk probability for each group is calculated. High-risk group probabilities are then added as new features to the original feature subset, generating a new feature subset to replace the original one, which is then used to retrain the RF model.

Results

The proposed method achieved an accuracy of 83.44%, sensitivity of 84.59%, specificity of 83.42%, and an area under the curve of 0.84.

Conclusion

The ML-based approach, coupled with feature aggregation, enhances predictive performance, aiding clinical teams in understanding crucial features and the model's decision-making process.

The effect of support surface on the prevention of pressure injury in acute care settings: A multi-center prospective observational study

PURPOSE

This study aimed to analyze if a multi-foam core mattress with a laminated cover can reduce the incidence of pressure injuries, compared to an alternating air mattress overlay among critically ill patients in acute settings.

DESIGN

Prospective observational study.

PARTICIPANTS

and setting: Patients with a Braden scale score ≤16 on intensive care unit admission at five general hospitals in Korea were included in this study between February 2022 and March 2022.

METHODS

One hundred and twenty patients in acute settings were enrolled and categorized into two groups: a multi-form core mattress with a laminated cover group (n = 60) and an alternating air mattress overlay group (n = 60). Data were collected for 7 days by wound care nurses.

RESULTS

Pressure injury developed at a significantly lower rate in the multi-form core mattress with a laminated cover group (n = 4/60, 6.7 %) than in the alternating air mattress overlay group (n = 25/60, 25.0 %) (P = 0.011). Using a multi-foam core mattress with a laminated cover demonstrated a protective effect against pressure injuries (odds ratio 0.123, 95 % confidence interval 0.024-0.620, P = 0.011).

CONCLUSIONS

A multi-foam core mattress with a laminated cover was significantly more effective than an alternating air mattress overlay in preventing pressure injury in critically ill patients.

Nursing care bundles in the prevention of medical device related pressure ulcers: An integrative review

The aim of this integrative review was to explore the effect of care bundles in the prevention of Medical Device Related Pressure Ulcers (MDRPU). An MDRPU is a wound that occurs on the skin or mucosal membranes because of pressure or pressure in combination with shear. Like other types of pressure ulcers, they will have negative consequences for patients and healthcare organisations alike. Many MDRPU's are preventable. A literature search was undertaken from computerised databases using key search terms, Pressure Ulcer* Pressure Injur* and Medical Device*. Databases included CINAHL; Medline and SocIndex. A total of seven studies were found that met the criteria for inclusion in this review. When compared to the widely recognised and trusted international guidelines there was variation found between the individual interventions selected within each study for inclusion within the bundle. Skin assessment and device repositioning were the most frequently included interventions in the bundles, followed by use of prophylactic dressings, appropriate device selection and fitting. The least common intervention was monitoring the tension of the device and/or its securements. All studies reported a reduction in the number of MDRPU's when care bundles were used in clinical practice. However, there is variation in bundle designs and study methodologies employed. This review has demonstrated the potential benefit of care bundles in reducing MDRPU. However, due to heterogeneity in the study methods employed and the interventions within the care bundles, further, more robust research is required to establish which interventions show the most clinical and patient benefit.

Film-forming polymer solutions containing cholesterol myristate and berberine mediate pressure ulcer repair via the Wnt/β-catenin pathway

Pressure ulcer (PU) is a worldwide problem that is difficult to address because of the related inflammatory response, local hypoxia, and repeated ischaemia/reperfusion, causing great suffering and financial burden to patients. Traditional Chinese medicine turtle plate powder can treat skin trauma, but its composition is complex and inconvenient to use. Here, we combined cholesterol myristate (S8) with berberine (BBR), with anti-inflammatory and antibacterial effects, as a drug and used hydroxypropyl methylcellulose and polyvinylpyrrolidone K30 as carriers to construct a novel film-forming polymeric solution (S8 + BBR FFPS), comprehensively study its reparative effect on PU and explore the potential mechanism in rat PU models. The results showed that S8 + BBR FFPS inhibits excessive inflammatory response, promotes re-epithelialization, and promotes hair follicle growth during the healing process of PU, which may be related to the activation of the Wnt/β-catenin signalling pathway by S8 + BBR FFPS to mediate hair follicle stem cell proliferation and maintain skin homeostasis. Therefore, S8 + BBR FFPS may be a potential candidate for the treatment of chronic skin injury, and its association with the Wnt/β-catenin signalling pathway may provide new ideas to guide the design of biomaterial-based wound dressings for chronic wound repair.

Pressure ulcers in German hospitals: Analysis of reimbursement and length of stay

Objective

Hospital-acquired pressure ulcers are an important indicator of the quality of care. Most pressure ulcers are avoidable with a robust protocol for prevention, but prevention activities often have a low priority for senior management because the true costs to the hospital are not visible. Our aim was to raise awareness of the value of pressure ulcer prevention by estimating the excess length of inpatient stay associated with hospital-acquired pressure ulcers, and by assessing whether additional costs are covered by increased reimbursement.

Methods

National activity data for hospitals in Germany are available through the InEK Data Browser. Data were extracted covering discharges from German hospitals between January 1 and December 31, 2021. Cases were selected according to the presence of a pressure ulcer diagnosis using ICD-10-GM codes L89.0-L89.3. Information was extracted for the ten most common German Diagnosis-Related Group (G-DRG) codes in patients with a secondary pressure ulcer diagnosis on mean length of stay and average reimbursement. Ulcer-associated excess length of stay was estimated by comparing cases within the same G-DRG with and without a pressure ulcer diagnosis.

Results

Mean length of stay was higher in patients with a pressure ulcer than in patients with no ulcer by between 1.9 (all ages) and 2.4 days (patients aged ≥65) per case. In patients aged ≥65 years, 22.1% of cases with a pressure ulcer had a length of stay above the norm for the DRG. In the German system length of stay above the norm is not normally reimbursed. Excess length of stay between 1.9 and 2.4 days leads to a potential cost to a hospital of between 1,633€ and 2,074€ per case.

Conclusion

Hospital-acquired pressure ulcers represent an important source of cost for a hospital which highlights the potential value of effective prevention.

Prevalence of hospital-acquired pressure injuries in intensive care units of the Eastern Mediterranean region: a systematic review and meta-analysis

BACKGROUND

Hospital-acquired pressure injuries are a major patient safety concern in intensive care units that are considered largely preventable adverse events by adherence to nursing standards of care. The hypothesis of this research was to investigate the prevalence of hospital-acquired pressure injuries in intensive care units (ICUs) of the Eastern Mediterranean Region.

METHODS

This study was designed as a systematic review and meta-analysis. All articles published on Pressure ulcer prevalence in the ICUs of hospitals in Eastern Mediterranean Region countries, identified by searching PubMed through MEDLINE, Web of Science, Scopus, and Google Scholar from January 1, 2011, until September 22, 2023. The reference lists of these articles were checked for additional relevant studies. Data were analyzed using the Comprehensive Meta-Analysis Software (v.2.2.064).

RESULTS

A total of 15 articles met the inclusion criteria. Based on the random-effects model, the overall Pressure ulcer prevalence rate was 16.6% (95% CI (8.6-29.6)). Both the highest and lowest prevalence was observed in Jordan in 2011 at 83.1% (95% CI (71.2- 90.7)) and in 2012 at 0.9% (95% CI (0.5- 1.5)), respectively. The results showed that publication year, average age, and sample size were the main causes of heterogeneity between the reviewed studies (p < 0.05).

CONCLUSION

This systematic review and meta-analysis of the pertinent peer-reviewed literature revealed a high prevalence of hospital-acquired pressure injuries of 16% in intensive care units of Eastern Mediterranean region. Therefore, it is necessary for health policymakers and managers in Eastern Mediterranean Region to take necessary measures to prevent the incidence of Pressure ulcers in hospitals, especially in ICUs.

Prevalence of hospital-acquired pressure injuries in intensive care units of the Eastern Mediterranean region: a systematic review and meta-analysis

BACKGROUND

Hospital-acquired pressure injuries are a major patient safety concern in intensive care units that are considered largely preventable adverse events by adherence to nursing standards of care. The hypothesis of this research was to investigate the prevalence of hospital-acquired pressure injuries in intensive care units (ICUs) of the Eastern Mediterranean Region.

METHODS

This study was designed as a systematic review and meta-analysis. All articles published on Pressure ulcer prevalence in the ICUs of hospitals in Eastern Mediterranean Region countries, identified by searching PubMed through MEDLINE, Web of Science, Scopus, and Google Scholar from January 1, 2011, until September 22, 2023. The reference lists of these articles were checked for additional relevant studies. Data were analyzed using the Comprehensive Meta-Analysis Software (v.2.2.064).

RESULTS

A total of 15 articles met the inclusion criteria. Based on the random-effects model, the overall Pressure ulcer prevalence rate was 16.6% (95% CI (8.6-29.6)). Both the highest and lowest prevalence was observed in Jordan in 2011 at 83.1% (95% CI (71.2- 90.7)) and in 2012 at 0.9% (95% CI (0.5- 1.5)), respectively. The results showed that publication year, average age, and sample size were the main causes of heterogeneity between the reviewed studies (p < 0.05).

CONCLUSION

This systematic review and meta-analysis of the pertinent peer-reviewed literature revealed a high prevalence of hospital-acquired pressure injuries of 16% in intensive care units of Eastern Mediterranean region. Therefore, it is necessary for health policymakers and managers in Eastern Mediterranean Region to take necessary measures to prevent the incidence of Pressure ulcers in hospitals, especially in ICUs.

Repositioning for pressure injury prevention in adults: a commentary on a Cochrane review

Repositioning is regarded as an important intervention to prevent the development of pressure injuries in patients who are immobile. However, there is uncertainty as to the optimal regimen in terms of frequency and method of repositioning. This commentary summarises and critically appraises a Cochrane systematic review that assessed the clinical and costeffectiveness of different repositioning regimens on the prevention of pressure injuries in adults in any setting.

Pressure injury incidence and impact on patients treated with prone positioning for COVID-19 ARDS

OBJECTIVE

To determine the incidence of pressure injuries (PIs) and their impact on clinical outcomes in patients treated with prone positioning for COVID-19 acute respiratory distress syndrome (ARDS).

METHOD

All patients with COVID-19 ARDS who were treated with prone positioning were categorised as cases and those who were not treated with prone positioning were categorised as controls. Demographics, clinical data and confounding variables affecting outcomes were recorded. Outcome variables of mortality and length of stay in intensive care units (ICUs) for both groups were recorded. Both groups' incidence of PIs were recorded and compared using statistical tests. Fisher's exact test was used for categorical variables, and Mann-Whitney U test was used for continuous variables.

RESULTS

The sample included 212 patients, treated with prone position (n=104) and without prone treatment (n=108). The incidence of PIs was n=75 (35.4%). PIs were significantly higher in patients in the prone position (n=51, 49%) compared with patients who were not (n=24, 22%); p=0.001. Patients in the prone position were found to have lower APACHE-2 scores, longer stays on the ventilator, ICU and in the hospital.

CONCLUSION

PIs are more prevalent in patients in the prone position and it adversely impacts clinical outcomes; it prolongs the length of stay on the ventilator, in the ICU and in the hospital.

Pressure Ulcers and Dressings: A Strain Sensitivity Analysis of the Boundary Conditions of a Finite Element Model

Recently, a new bi-layer dressing was proposed by Urgo RID to reduce the healing time of pressure ulcers (PU). This dressing was numerically evaluated in previously published work. In the current work, the influence on the maximal shear strains of modelling parameters such as the dressing local geometry, the pressure applied by the gauze inside the wound, the wound deepness, and the mattress stiffness, was assessed. A sensitivity analysis was performed on these four parameters. Among all experiments, the mean maximal Green–Lagrange shear strain was 0.29. The gauze pressure explained 60% of the model response in terms of the volume of tissues under strains of 0.3, while the wound deepness explained 28%. The mattress had a significant, but low impact, whereas the dressing local geometry had no significant impact. As expected, the wound deepness was one of the most influential parameters. The gauze turned out to be more significant than expected. This may be explained by the large range of values chosen for this study. The results should be extended to more subjects, but still suggest that the gauze is a parameter that might not be neglected. Care should also be taken in clinical practice when using gauze that could have either a positive or negative impact on the soft tissues’ strains. This may also depend on the wound deepness.

Two factors that can increase the length of hospital stay of patients with dementia

OBJECTIVES

Patients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.

METHODS/DESIGN

We conducted a retrospective analysis on a cross-sectional hospital dataset for the period January-December 2016. Excluding length of stay less than 24h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.

RESULTS

The highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778-3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029-3.045).

CONCLUSIONS

Based on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.

Interventions for the treatment and prevention of pressure ulcers

Pressure ulcers can affect multiple aspects of an individual's life. Though preventable, pressure ulcers place a substantial economic burden on healthcare services. Countries around the world have set pressure ulcer prevention and treatment as a high priority. National Clinical Guidelines recommend a wide range of preventative and curative treatments. However, there is still much uncertainty regarding the effectiveness of preventative and curative treatments. This overview of systematic reviews aims to describe the findings of 15 Cochrane reviews on the treatment and prevention of pressure ulcers included in a previous umbrella review and to expand upon their findings in the context of clinical practice.

Factors Facilitating and Hindering the Use of Newly Acquired Positioning Skills in Clinical Practice: A Longitudinal Survey

Background

After learning new skills, healthcare professionals do not always apply them in practice, despite being motivated. This may be referred to as an intention-behavior gap. One example is the positioning of immobilized and disabled patients in hospitals, nursing homes, or neurorehabilitation clinics. Positioning is crucial to prevent complications such as pressure sores, pneumonia, and deep vein thrombosis. However, it is often not carried out optimally even when professionals have completed education programs. The LiN-method is a positioning procedure involving a special focus on aligning and stabilizing body parts, which has been shown to have advantages over conventional positioning. We assess which factors may facilitate or hinder the use of LiN in clinical practice after participants complete training.

Methods

A longitudinal survey with 101 LiN-course participants was conducted in Germany. Each participant completed a questionnaire directly after the course and 12 weeks later, including a report of the frequency of use in practice. They also completed a questionnaire which surveyed 23 aspects that might facilitate or hinder use of the new skills, covering the workplace, socio-collegial factors, motivation, self-confidence, and mindset.

Results

Most assessed aspects were associated with LiN-use, with the highest correlations found for confidence with the method, perceived ease of application, sufficient time, assessing one's skills as sufficient, remembering the relevant steps, and a work environment open to advanced therapeutic concepts. To reduce data complexity, the questionnaire was subjected to a factor analysis, revealing six factors. A regression analysis showed that four factors predicted use 12 weeks after course completion, in the following order of importance: (1) subjective aspects/confidence, (2) access to materials, (3) work context, and (4) competent support in the workplace.

Conclusion

Numerous aspects are associated with the use of recently acquired clinical or nursing skills, such as LiN. Many of these can be improved by appropriately setting up the workplace. The aspects most associated with use, however, are confidence with the method and self-perceived competence of healthcare professionals. While causality still needs to be demonstrated, this suggests that education programs should support participants in developing confidence and foster a mindset of continuous learning.

Prediction of inpatient pressure ulcers based on routine healthcare data using machine learning methodology

Despite the relevance of pressure ulcers (PU) in inpatient care, the predictive power and role of care-related risk factors (e.g. anesthesia) remain unclear. We investigated the predictability of PU incidence and its association with multiple care variables. We included all somatic cases between 2014 and 2018 with length of stay ≥ 2d in a German university hospital. For regression analyses and prediction we used Bayesian Additive Regression Trees (BART) as nonparametric modeling approach. To assess predictive accuracy, we compared BART, random forest, logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) using area under the curve (AUC), confusion matrices and multiple indicators of predictive performance (e.g. sensitivity, specificity, F1, positive/ negative predictive value) in the full dataset and subgroups. Analysing 149,006 cases revealed high predictive variable importance and associations between incident PU and ventilation, age, anesthesia (≥ 1 h) and number of care-involved wards. Despite high AUCs (range 0.89–0.90), many false negative predictions led to low sensitivity (range 0.04–0.10). Ventilation, age, anesthesia and number of care-involved wards were associated with incident PU. Using anesthesia as a proxy for immobility, an hourly repositioning is indicated. The low sensitivity indicates major challenges for correctly predicting PU based on routine data.

Risk factors for pressure ulcers in adult patients: A meta-analysis on sociodemographic factors and the Braden scale

AIMS AND OBJECTIVES

Providing the first meta-analysis of risk factors for pressure ulcer development in adult patients.

BACKGROUND

Pressure ulcers remain a serious health complication for patients and nursing staff. However, there is a lack of statistical evidence for risk factors as previous research did not include any quantitative synthesis.

DESIGN

Meta-analysis, using PRISMA guidelines.

METHODS

Studies from PubMed, Embase, CINAHL Complete, Web of Science, Cochrane Library, and other reviews and sources were screened and checked against the inclusion criteria. The risk of bias was evaluated using a slightly modified QUIPS tool. Data regarding population, design, statistical analysis and risk factors were extracted. Meta-analysis with comparable studies was conducted for age, sex, and Braden scale. The sub-group analysis was used to account for heterogeneity.

RESULTS

28 studies with 570,162 patients were entered in meta-analysis. Older age and a low total Braden scale score increased the risk for pressure ulcers. All subscales excluding 'moisture' reached significance in meta-analysis based only on few studies, however, limiting overall evidence. Male sex achieved mixed results, too.

CONCLUSION

The first meta-analytic analysis shows evidence for age and Braden scale as risk factors for pressure ulcer development. Limitations regarding study quality and heterogeneity must be considered, highlighting the need for unifying certain conditions in risk factor research.

RELEVANCE TO CLINICAL PRACTICE

Patients at risk for new pressure ulcers can be identified by their total Braden score and age, whereas the latter is also connected to deeper pressure ulcers. Nurses and health personnel should pay great attention to patients in older age and undergo specific training to utilise and evaluate the Braden scale effectively, if necessary.

The skin microbiome of infected pressure ulcers: A review and implications for health professionals

BACKGROUND

Pressure ulcers (PUs) are injuries resulting from ischaemia caused by prolonged compression or shear forces on the skin, adjacent tissues and bones. Advanced stages of PUs are associated with infectious complications and constitute a major clinical challenge, with high social and economic impacts in health care.

GOALS

This study aims to identify and describe the relationship between PU risk factors, stages and anatomical locations, and the relevance of microbial cohabitation and biofilm growth.

METHODS

The narrative review method to advocating a critical and objective analysis of the current knowledge on the topic was performed. Indexed databases and direct consultation to specialized and high-impact journals on the subject were used to extract relevant information, guided by co-authors. The Medical Subject Headings of pressure ulcer (or injury), biofilms, infection and other analogues terms were used.

RESULTS

Development of PUs and consequent infection depends on several direct and indirect risk factors, including cutaneous/PU microbiome, microclimate and behavioural factors. Infected PUs are polymicrobial and characterized by biofilm-associated infection, phenotypic hypervariability of species and inherent resistance to antimicrobials. The different stages and anatomical locations also play an important role in their colonization. The prevention and monitoring of PUs remain crucial for avoiding the emergence of systemic infections and reducing health care-associated costs, improve the quality of life of patients and reduce the mortality-associated infected PUs.

Predictors of Pressure Injury Prevention Practices Among ICU Nurses in China

OBJECTIVE

To explore the predictors of knowledge of pressure injury (PI) prevention, attitudes on PI prevention, organization support for PI prevention, and the influence of a healthy work environment (HWE) on PI prevention practices among ICU nurses in China.

METHODS

A descriptive, predictive, online survey was conducted among 510 ICU nurses in Guizhou province, China. A PI prevention knowledge questionnaire, PI prevention attitude questionnaire, organizational support for PI prevention questionnaire, HWE assessment tool, and PI prevention practice questionnaire were used for data collection. A hierarchical regression analysis was used to determine the influence of certain predictive factors.

RESULTS

An HWE, organizational support for PI prevention, and positive attitudes toward PI prevention were significant predictors of good practice regarding PI prevention. However, knowledge of PI prevention was not a significant predictor.

CONCLUSIONS

To achieve optimal nursing quality in terms of PI prevention, hospital and nursing administrators should develop strategies or interventions to create and sustain an HWE and supportive organizational culture for ICU nurses and enhance positive attitudes toward PI prevention.

Risk factors associated with heel pressure ulcer development in adult population: A systematic literature review

AIMS

The main aim of this systematic literature review was to identify risk factors for development of heel pressure ulcers and quantify their effect.

BACKGROUND

Pressure ulcers remain one of the key patient safety challenges across all health care settings and heels are the second most common site for developing pressure ulcers after the sacrum.

DESIGN

Quantitative systematic review.

METHODS

Data sources: Electronic databases were searched for studies published between 1809 to March 2020 using keywords, Medical Subject Headings, and other index terms, as well as combinations of these terms and appropriate synonyms.

STUDY ELIGIBILITY CRITERIA

Previous systematic literature reviews, cohort, case control and cross-sectional studies investigating risk factors for developing heel pressure ulcers. Only articles published in English were reviewed with no restrictions on date of publication.

PARTICIPANTS

patients aged 18 years and above in any care setting. Study selection, data extraction, risk of bias and quality assessment were completed by two independent reviewers. Disagreements were resolved by discussion.

RESULTS

Thirteen studies met the eligibility criteria and several potential risk factors were identified. However, eligible studies were mainly moderate to low quality except for three high quality studies.

CONCLUSIONS

There is a paucity of high quality evidence to identify risk factors associated with heel pressure ulcer development. Immobility, diabetes, vascular disease, impaired nutrition, perfusion issues, mechanical ventilation, surgery, and Braden subscales were identified as potential risk factors for developing heel pressure ulcers however, further well-designed studies are required to elucidate these factors. Other risk factors may also exist and require further investigation.

PROSPERO ID

PROSPERO International prospective register of systematic reviews: CRD42017071459.

Intensive Care Nurses' Knowledge, Attitude, and Practice of Pressure Injury Prevention in China: A Cross-Sectional Study

Background

Pressure injury (PI) remains a critical health issue worldwide. The global incidence of hospital-acquired PI is 8.4%, and among intensive-care unit (ICU) patients, it is even higher, ranging from 6.60% to 36.80%. It is important to investigate ICU nurses’ PI prevention knowledge, attitudes, and practices (KAP).

Aim

The aim of this study was to describe the level of Chinese ICU nurses’ knowledge, attitudes, and self-reported practices of PI prevention.

Materials and Methods

From March 31 to April 30, 2019, we recruited a total of 510 ICU nurses into the current study using convenience sampling. The Modified Pressure Ulcer Knowledge Assessment Tool version 2.0, Attitudes toward Pressure Ulcer Prevention instrument, and Questionnaire to evaluate nurses’ Adherence to Recommendations for Preventing Pressure Ulcers were used for data collection. We used one-way analysis of variance, Student’s t-test, and the Mann–Whitney U-test to assess differences in knowledge, attitudes, and self-reported practices of PI prevention among ICU nurses, whom we categorized by their demographic characteristics.

Results

Mean scores of participants’ knowledge, attitude, and their self-report practice were 65.82 ± 9.29, 76.65 ± 8.62, and 83.35 ± 13.55, respectively. Participants with bachelor’s degrees or higher, who worked in tertiary hospitals, and who had received training on PI prevention over the last year had higher scored on PI prevention knowledge (all P < 0.05). Participants who had received training on PI prevention over the last year scored higher on attitude than those who had not received such training over the last year (P = 0.001).

Conclusion

ICU nurses surveyed in this study did not demonstrate an acceptable level of knowledge about PI prevention, while their attitudes and self-reported practices were acceptable. Continuing education or in-service training should be provided to enhance ICU nurses’ knowledge of PI prevention.

Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis

BACKGROUND

Pressure ulcers (also known as pressure injuries, pressure sores and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Specific kinds of beds, overlays and mattresses are widely used with the aim of preventing and treating pressure ulcers.

OBJECTIVES

To summarise evidence from Cochrane Reviews that assess the effects of beds, overlays and mattresses on reducing the incidence of pressure ulcers and on increasing pressure ulcer healing in any setting and population. To assess the relative effects of different types of beds, overlays and mattresses for reducing the incidence of pressure ulcers and increasing pressure ulcer healing in any setting and population. To cumulatively rank the different treatment options of beds, overlays and mattresses in order of their effectiveness in pressure ulcer prevention and treatment.

METHODS

In July 2020, we searched the Cochrane Library. Cochrane Reviews reporting the effectiveness of beds, mattresses or overlays for preventing or treating pressure ulcers were eligible for inclusion in this overview. Two review authors independently screened search results and undertook data extraction and risk of bias assessment using the ROBIS tool. We summarised the reported evidence in an overview of reviews. Where possible, we included the randomised controlled trials from each included review in network meta-analyses. We assessed the relative effectiveness of beds, overlays and mattresses for preventing or treating pressure ulcers and their probabilities of being, comparably, the most effective treatment. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We include six Cochrane Reviews in this overview of reviews, all at low or unclear risk of bias. Pressure ulcer prevention: four reviews (of 68 studies with 18,174 participants) report direct evidence for 27 pairwise comparisons between 12 types of support surface on the following outcomes: pressure ulcer incidence, time to pressure ulcer incidence, patient comfort response, adverse event rates, health-related quality of life, and cost-effectiveness. Here we focus on outcomes with some evidence at a minimum of low certainty. (1) Pressure ulcer incidence: our overview includes direct evidence for 27 comparisons that mostly (19/27) have very low-certainty evidence concerning reduction of pressure ulcer risk. We included 40 studies (12,517 participants; 1298 participants with new ulcers) in a network meta-analysis involving 13 types of intervention. Data informing the network are sparse and this, together with the high risk of bias in most studies informing the network, means most network contrasts (64/78) yield evidence of very low certainty. There is low-certainty evidence that, compared with foam surfaces (reference treatment), reactive air surfaces (e.g. static air overlays) (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.29 to 0.75), alternating pressure (active) air surfaces (e.g. alternating pressure air mattresses, large-celled ripple mattresses) (RR 0.63, 95% CI 0.42 to 0.93), and reactive gel surfaces (e.g. gel pads used on operating tables) (RR 0.47, 95% CI 0.22 to 1.01) may reduce pressure ulcer incidence. The ranking of treatments in terms of effectiveness is also of very low certainty for all interventions. It is unclear which treatment is best for preventing ulceration. (2) Time to pressure ulcer incidence: four reviews had direct evidence on this outcome for seven comparisons. We included 10 studies (7211 participants; 699 participants with new ulcers) evaluating six interventions in a network meta-analysis. Again, data from most network contrasts (13/15) are of very low certainty. There is low-certainty evidence that, compared with foam surfaces (reference treatment), reactive air surfaces may reduce the hazard of developing new pressure ulcers (hazard ratio (HR) 0.20, 95% CI 0.04 to 1.05). The ranking of all support surfaces for preventing pressure ulcers in terms of time to healing is uncertain. (3) Cost-effectiveness: this overview includes direct evidence for three comparisons. For preventing pressure ulcers, alternating pressure air surfaces are probably more cost-effective than foam surfaces (moderate-certainty evidence). Pressure ulcer treatment: two reviews (of 12 studies with 972 participants) report direct evidence for five comparisons on: complete pressure ulcer healing, time to complete pressure ulcer healing, patient comfort response, adverse event rates, and cost-effectiveness. Here we focus on outcomes with some evidence at a minimum of low certainty. (1) Complete pressure ulcer healing: our overview includes direct evidence for five comparisons. There is uncertainty about the relative effects of beds, overlays and mattresses on ulcer healing. The corresponding network meta-analysis (with four studies, 397 participants) had only three direct contrasts and a total of six network contrasts. Again, most network contrasts (5/6) have very low-certainty evidence. There was low-certainty evidence that more people with pressure ulcers may heal completely using reactive air surfaces than using foam surfaces (RR 1.32, 95% CI 0.96 to 1.80). We are uncertain which surfaces have the highest probability of being the most effective (all very low-certainty evidence). (2) Time to complete pressure ulcer healing: this overview includes direct evidence for one comparison: people using reactive air surfaces may be more likely to have healed pressure ulcers compared with those using foam surfaces in long-term care settings (HR 2.66, 95% CI 1.34 to 5.17; low-certainty evidence). (3) Cost-effectiveness: this overview includes direct evidence for one comparison: compared with foam surfaces, reactive air surfaces may cost an extra 26 US dollars for every ulcer-free day in the first year of use in long-term care settings (low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared with foam surfaces, reactive air surfaces may reduce pressure ulcer risk and may increase complete ulcer healing. Compared with foam surfaces, alternating pressure air surfaces may reduce pressure ulcer risk and are probably more cost-effective in preventing pressure ulcers. Compared with foam surfaces, reactive gel surfaces may reduce pressure ulcer risk, particularly for people in operating rooms and long-term care settings. There are uncertainties for the relative effectiveness of other support surfaces for preventing and treating pressure ulcers, and their efficacy ranking. More high-quality research is required; for example, for the comparison of reactive air surfaces with alternating pressure air surfaces. Future studies should consider time-to-event outcomes and be designed to minimise any risk of bias.

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective

Aims

This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service.

Methods and results

We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day‐case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard‐of‐care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service—78 (68.4%) on a day‐case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out‐patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow‐up, there were 20 (17.5%) 30 day re‐admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard‐of‐care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001).

Conclusions

Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID‐19.

Alternating pressure (active) air surfaces for preventing pressure ulcers

BACKGROUND

Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Alternating pressure (active) air surfaces are widely used with the aim of preventing pressure ulcers.

OBJECTIVES

To assess the effects of alternating pressure (active) air surfaces (beds, mattresses or overlays) compared with any support surface on the incidence of pressure ulcers in any population in any setting.

SEARCH METHODS

In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that allocated participants of any age to alternating pressure (active) air beds, overlays or mattresses. Comparators were any beds, overlays or mattresses.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.

MAIN RESULTS

We included 32 studies (9058 participants) in the review. Most studies were small (median study sample size: 83 participants). The average age of participants ranged from 37.2 to 87.0 years (median: 69.1 years). Participants were largely from acute care settings (including accident and emergency departments). We synthesised data for six comparisons in the review: alternating pressure (active) air surfaces versus: foam surfaces, reactive air surfaces, reactive water surfaces, reactive fibre surfaces, reactive gel surfaces used in the operating room followed by foam surfaces used on the ward bed, and another type of alternating pressure air surface. Of the 32 included studies, 25 (78.1%) presented findings which were considered at high overall risk of bias.

PRIMARY OUTCOME

pressure ulcer incidence Alternating pressure (active) air surfaces may reduce the proportion of participants developing a new pressure ulcer compared with foam surfaces (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.34 to 1.17; I² = 63%; 4 studies, 2247 participants; low-certainty evidence). Alternating pressure (active) air surfaces applied on both operating tables and hospital beds may reduce the proportion of people developing a new pressure ulcer compared with reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (RR 0.22, 95% CI 0.06 to 0.76; I² = 0%; 2 studies, 415 participants; low-certainty evidence). It is uncertain whether there is a difference in the proportion of people developing new pressure ulcers between alternating pressure (active) air surfaces and the following surfaces, as all these comparisons have very low-certainty evidence: (1) reactive water surfaces; (2) reactive fibre surfaces; and (3) reactive air surfaces. The comparisons between different types of alternating pressure air surfaces are presented narratively. Overall, all comparisons suggest little to no difference between these surfaces in pressure ulcer incidence (7 studies, 2833 participants; low-certainty evidence). Included studies have data on time to pressure ulcer incidence for three comparisons. When time to pressure ulcer development is considered using a hazard ratio (HR), it is uncertain whether there is a difference in the risk of developing new pressure ulcers, over 90 days' follow-up, between alternating pressure (active) air surfaces and foam surfaces (HR 0.41, 95% CI 0.10 to 1.64; I² = 86%; 2 studies, 2105 participants; very low-certainty evidence). For the comparison with reactive air surfaces, there is low-certainty evidence that people treated with alternating pressure (active) air surfaces may have a higher risk of developing an incident pressure ulcer than those treated with reactive air surfaces over 14 days' follow-up (HR 2.25, 95% CI 1.05 to 4.83; 1 study, 308 participants). Neither of the two studies with time to ulcer incidence data suggested a difference in the risk of developing an incident pressure ulcer over 60 days' follow-up between different types of alternating pressure air surfaces. Secondary outcomes The included studies have data on (1) support-surface-associated patient comfort for comparisons involving foam surfaces, reactive air surfaces, reactive fibre surfaces and alternating pressure (active) air surfaces; (2) adverse events for comparisons involving foam surfaces, reactive gel surfaces and alternating pressure (active) air surfaces; and (3) health-related quality of life outcomes for the comparison involving foam surfaces. However, all these outcomes and comparisons have low or very low-certainty evidence and it is uncertain whether there are any differences in these outcomes. Included studies have data on cost effectiveness for two comparisons. Moderate-certainty evidence suggests that alternating pressure (active) air surfaces are probably more cost-effective than foam surfaces (1 study, 2029 participants) and that alternating pressure (active) air mattresses are probably more cost-effective than overlay versions of this technology for people in acute care settings (1 study, 1971 participants).

AUTHORS' CONCLUSIONS

Current evidence is uncertain about the difference in pressure ulcer incidence between using alternating pressure (active) air surfaces and other surfaces (reactive water surfaces, reactive fibre surfaces and reactive air surfaces). Alternating pressure (active) air surfaces may reduce pressure ulcer risk compared with foam surfaces and reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds. People using alternating pressure (active) air surfaces may be more likely to develop new pressure ulcers over 14 days' follow-up than those treated with reactive air surfaces in the nursing home setting; but as the result is sensitive to the choice of outcome measure it should be interpreted cautiously. Alternating pressure (active) air surfaces are probably more cost-effective than reactive foam surfaces in preventing new pressure ulcers. Future studies should include time-to-event outcomes and assessment of adverse events and trial-level cost-effectiveness. Further review using network meta-analysis will add to the findings reported here.

Reactive air surfaces for preventing pressure ulcers

BACKGROUND

Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Reactive air surfaces (beds, mattresses or overlays) can be used for preventing pressure ulcers.

OBJECTIVES

To assess the effects of reactive air beds, mattresses or overlays compared with any support surface on the incidence of pressure ulcers in any population in any setting.

SEARCH METHODS

In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that allocated participants of any age to reactive air beds, overlays or mattresses. Comparators were any beds, overlays or mattresses that were applied for preventing pressure ulcers.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a reactive air surface was compared with surfaces that were not clearly specified, then we recorded and described the concerned study but did not included it in further data analyses.

MAIN RESULTS

We included 17 studies (2604 participants) in this review. Most studies were small (median study sample size: 83 participants). The average participant age ranged from 56 to 87 years (median: 72 years). Participants were recruited from a wide range of care settings with the majority being acute care settings. Almost all studies were conducted in the regions of Europe and America. Of the 17 included studies, two (223 participants) compared reactive air surfaces with surfaces that were not well described and therefore could not be classified. We analysed data for five comparisons: reactive air surfaces compared with (1) alternating pressure (active) air surfaces (seven studies with 1728 participants), (2) foam surfaces (four studies with 229 participants), (3) reactive water surfaces (one study with 37 participants), (4) reactive gel surfaces (one study with 66 participants), and (5) another type of reactive air surface (two studies with 223 participants). Of the 17 studies, seven (41.2%) presented findings which were considered at high overall risk of bias.

PRIMARY OUTCOME

Pressure ulcer incidence Reactive air surfaces may reduce the proportion of participants developing a new pressure ulcer compared with foam surfaces (risk ratio (RR) 0.42; 95% confidence interval (CI) 0.18 to 0.96; I2 = 25%; 4 studies, 229 participants; low-certainty evidence). It is uncertain if there is a difference in the proportions of participants developing a new pressure ulcer on reactive air surfaces compared with: alternating pressure (active) air surfaces (6 studies, 1648 participants); reactive water surfaces (1 study, 37 participants); reactive gel surfaces (1 study, 66 participants), or another type of reactive air surface (2 studies, 223 participants). Evidence for all these comparisons is of very low certainty. Included studies have data on time to pressure ulcer incidence for two comparisons. When time to pressure ulcer incidence is considered using a hazard ratio (HR), low-certainty evidence suggests that in the nursing home setting, people on reactive air surfaces may be less likely to develop a new pressure ulcer over 14 days' of follow-up than people on alternating pressure (active) air surfaces (HR 0.44; 95% CI 0.21 to 0.96; 1 study, 308 participants). It is uncertain if there is a difference in the hazard of developing new pressure ulcers between two types of reactive air surfaces (1 study, 123 participants; very low-certainty evidence). Secondary outcomes Support-surface-associated patient comfort: the included studies have data on this outcome for three comparisons. We could not pool any data as comfort outcome measures differed between included studies; therefore a narrative summary is provided. It is uncertain if there is a difference in patient comfort responses between reactive air surfaces and foam surfaces over the top of an alternating pressure (active) air surfaces (1 study, 72 participants), and between those using reactive air surfaces and those using alternating pressure (active) air surfaces (4 studies, 1364 participants). Evidence for these two comparisons is of very low certainty. It is also uncertain if there is a difference in patient comfort responses between two types of reactive air surfaces (1 study, 84 participants; low-certainty evidence). All reported adverse events: there were data on this outcome for one comparison: it is uncertain if there is a difference in adverse events between reactive air surfaces and foam surfaces (1 study, 72 participants; very low-certainty evidence). The included studies have no data for health-related quality of life and cost-effectiveness for all five comparisons.

AUTHORS' CONCLUSIONS

Current evidence is uncertain regarding any differences in the relative effects of reactive air surfaces on ulcer incidence and patient comfort, when compared with reactive water surfaces, reactive gel surfaces, or another type of reactive air surface. Using reactive air surfaces may reduce the risk of developing new pressure ulcers compared with using foam surfaces. Also, using reactive air surfaces may reduce the risk of developing new pressure ulcers within 14 days compared with alternating pressure (active) air surfaces in people in a nursing home setting. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision-makers. Time-to-event outcomes, careful assessment of adverse events and trial-level cost-effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and adjudicators of the photographs being blinded to group allocation. Further review using network meta-analysis will add to the findings reported here.

Foam surfaces for preventing pressure ulcers

BACKGROUND

Pressure ulcers (also known as pressure injuries) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Foam surfaces (beds, mattresses or overlays) are widely used with the aim of preventing pressure ulcers.

OBJECTIVES

To assess the effects of foam beds, mattresses or overlays compared with any support surface on the incidence of pressure ulcers in any population in any setting.

SEARCH METHODS

In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that allocated participants of any age to foam beds, mattresses or overlays. Comparators were any beds, mattresses or overlays.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a foam surface was compared with surfaces that were not clearly specified, then the included study was recorded and described but not considered further in any data analyses.

MAIN RESULTS

We included 29 studies (9566 participants) in the review. Most studies were small (median study sample size: 101 participants). The average age of participants ranged from 47.0 to 85.3 years (median: 76.0 years). Participants were mainly from acute care settings. We analysed data for seven comparisons in the review: foam surfaces compared with: (1) alternating pressure air surfaces, (2) reactive air surfaces, (3) reactive fibre surfaces, (4) reactive gel surfaces, (5) reactive foam and gel surfaces, (6) reactive water surfaces, and (7) another type of foam surface. Of the 29 included studies, 17 (58.6%) presented findings which were considered at high overall risk of bias.

PRIMARY OUTCOME

pressure ulcer incidence Low-certainty evidence suggests that foam surfaces may increase the risk of developing new pressure ulcers compared with (1) alternating pressure (active) air surfaces (risk ratio (RR) 1.59, 95% confidence interval (CI) 0.86 to 2.95; I2 = 63%; 4 studies, 2247 participants), and (2) reactive air surfaces (RR 2.40, 95% CI 1.04 to 5.54; I2 = 25%; 4 studies, 229 participants). We are uncertain regarding the difference in pressure ulcer incidence in people treated with foam surfaces and the following surfaces: (1) reactive fibre surfaces (1 study, 68 participants); (2) reactive gel surfaces (1 study, 135 participants); (3) reactive gel and foam surfaces (1 study, 91 participants); and (4) another type of foam surface (6 studies, 733 participants). These had very low-certainty evidence. Included studies have data on time to pressure ulcer development for two comparisons. When time to ulcer development is considered using hazard ratios, the difference in the risk of having new pressure ulcers, over 90 days' follow-up, between foam surfaces and alternating pressure air surfaces is uncertain (2 studies, 2105 participants; very low-certainty evidence). Two further studies comparing different types of foam surfaces also reported time-to-event data, suggesting that viscoelastic foam surfaces with a density of 40 to 60 kg/m3 may decrease the risk of having new pressure ulcers over 11.5 days' follow-up compared with foam surfaces with a density of 33 kg/m3 (1 study, 62 participants); and solid foam surfaces may decrease the risk of having new pressure ulcers over one month's follow-up compared with convoluted foam surfaces (1 study, 84 participants). Both had low-certainty evidence. There was no analysable data for the comparison of foam surfaces with reactive water surfaces (one study with 117 participants). Secondary outcomes Support-surface-associated patient comfort: the review contains data for three comparisons for this outcome. It is uncertain if there is a difference in patient comfort measure between foam surfaces and alternating pressure air surfaces (1 study, 76 participants; very low-certainty evidence); foam surfaces and reactive air surfaces (1 study, 72 participants; very low-certainty evidence); and different types of foam surfaces (4 studies, 669 participants; very low-certainty evidence). All reported adverse events: the review contains data for two comparisons for this outcome. We are uncertain about differences in adverse effects between foam surfaces and alternating pressure (active) air surfaces (3 studies, 2181 participants; very low-certainty evidence), and between foam surfaces and reactive air surfaces (1 study, 72 participants; very low-certainty evidence). Health-related quality of life: only one study reported data on this outcome. It is uncertain if there is a difference (low-certainty evidence) between foam surfaces and alternating pressure (active) air surfaces in health-related quality of life measured with two different questionnaires, the EQ-5D-5L (267 participants) and the PU-QoL-UI (233 participants). Cost-effectiveness: one study reported trial-based cost-effectiveness evaluations. Alternating pressure (active) air surfaces are probably more cost-effective than foam surfaces in preventing pressure ulcer incidence (2029 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Current evidence suggests uncertainty about the differences in pressure ulcer incidence, patient comfort, adverse events and health-related quality of life between using foam surfaces and other surfaces (reactive fibre surfaces, reactive gel surfaces, reactive foam and gel surfaces, or reactive water surfaces). Foam surfaces may increase pressure ulcer incidence compared with alternating pressure (active) air surfaces and reactive air surfaces. Alternating pressure (active) air surfaces are probably more cost-effective than foam surfaces in preventing new pressure ulcers. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision-makers. Time-to-event outcomes, careful assessment of adverse events and trial-level cost-effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and by blinding adjudicators of the photographs to group allocation. Further review using network meta-analysis will add to the findings reported here.

Alternative reactive support surfaces (non-foam and non-air-filled) for preventing pressure ulcers

BACKGROUND

Pressure ulcers (also known as injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Reactive surfaces that are not made of foam or air cells can be used for preventing pressure ulcers.

OBJECTIVES

To assess the effects of non-foam and non-air-filled reactive beds, mattresses or overlays compared with any other support surface on the incidence of pressure ulcers in any population in any setting.

SEARCH METHODS

In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that allocated participants of any age to non-foam or non-air-filled reactive beds, overlays or mattresses. Comparators were any beds, overlays or mattresses used.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. If a non-foam or non-air-filled surface was compared with surfaces that were not clearly specified, then the included study was recorded and described but not considered further in any data analyses.

MAIN RESULTS

We included 20 studies (4653 participants) in this review. Most studies were small (median study sample size: 198 participants). The average participant age ranged from 37.2 to 85.4 years (median: 72.5 years). Participants were recruited from a wide range of care settings but were mainly from acute care settings. Almost all studies were conducted in Europe and America. Of the 20 studies, 11 (2826 participants) included surfaces that were not well described and therefore could not be fully classified. We synthesised data for the following 12 comparisons: (1) reactive water surfaces versus alternating pressure (active) air surfaces (three studies with 414 participants), (2) reactive water surfaces versus foam surfaces (one study with 117 participants), (3) reactive water surfaces versus reactive air surfaces (one study with 37 participants), (4) reactive water surfaces versus reactive fibre surfaces (one study with 87 participants), (5) reactive fibre surfaces versus alternating pressure (active) air surfaces (four studies with 384 participants), (6) reactive fibre surfaces versus foam surfaces (two studies with 228 participants), (7) reactive gel surfaces on operating tables followed by foam surfaces on ward beds versus alternating pressure (active) air surfaces on operating tables and subsequently on ward beds (two studies with 415 participants), (8) reactive gel surfaces versus reactive air surfaces (one study with 74 participants), (9) reactive gel surfaces versus foam surfaces (one study with 135 participants), (10) reactive gel surfaces versus reactive gel surfaces (one study with 113 participants), (11) reactive foam and gel surfaces versus reactive gel surfaces (one study with 166 participants) and (12) reactive foam and gel surfaces versus foam surfaces (one study with 91 participants). Of the 20 studies, 16 (80%) presented findings which were considered to be at high overall risk of bias.

PRIMARY OUTCOME

Pressure ulcer incidence We did not find analysable data for two comparisons: reactive water surfaces versus foam surfaces, and reactive water surfaces versus reactive fibre surfaces. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (14/205 (6.8%)) may increase the proportion of people developing a new pressure ulcer compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds (3/210 (1.4%) (risk ratio 4.53, 95% confidence interval 1.31 to 15.65; 2 studies, 415 participants; I² = 0%; low-certainty evidence). For all other comparisons, it is uncertain whether there is a difference in the proportion of participants developing new pressure ulcers as all data were of very low certainty. Included studies did not report time to pressure ulcer incidence for any comparison in this review. Secondary outcomes Support-surface-associated patient comfort: the included studies provide data on this outcome for one comparison. It is uncertain if there is a difference in patient comfort between alternating pressure (active) air surfaces and reactive fibre surfaces (one study with 187 participants; very low-certainty evidence). All reported adverse events: there is evidence on this outcome for one comparison. It is uncertain if there is a difference in adverse events between reactive gel surfaces followed by foam surfaces and alternating pressure (active) air surfaces applied on both operating tables and hospital beds (one study with 198 participants; very low-certainty evidence). We did not find any health-related quality of life or cost-effectiveness evidence for any comparison in this review.

AUTHORS' CONCLUSIONS

Current evidence is generally uncertain about the differences between non-foam and non-air-filled reactive surfaces and other surfaces in terms of pressure ulcer incidence, patient comfort, adverse effects, health-related quality of life and cost-effectiveness. Reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds may increase the risk of having new pressure ulcers compared with alternating pressure (active) air surfaces applied on both operating tables and hospital beds. Future research in this area should consider evaluation of the most important support surfaces from the perspective of decision-makers. Time-to-event outcomes, careful assessment of adverse events and trial-level cost-effectiveness evaluation should be considered in future studies. Trials should be designed to minimise the risk of detection bias; for example, by using digital photography and adjudicators of the photographs being blinded to group allocation. Further review using network meta-analysis will add to the findings reported here.

Predicting pressure injury using nursing assessment phenotypes and machine learning methods

OBJECTIVE

Pressure injuries are common and serious complications for hospitalized patients. The pressure injury rate is an important patient safety metric and an indicator of the quality of nursing care. Timely and accurate prediction of pressure injury risk can significantly facilitate early prevention and treatment and avoid adverse outcomes. While many pressure injury risk assessment tools exist, most were developed before there was access to large clinical datasets and advanced statistical methods, limiting their accuracy. In this paper, we describe the development of machine learning-based predictive models, using phenotypes derived from nurse-entered direct patient assessment data.

METHODS

We utilized rich electronic health record data, including full assessment records entered by nurses, from 5 different hospitals affiliated with a large integrated healthcare organization to develop machine learning-based prediction models for pressure injury. Five-fold cross-validation was conducted to evaluate model performance.

RESULTS

Two pressure injury phenotypes were defined for model development: nonhospital acquired pressure injury (N = 4398) and hospital acquired pressure injury (N = 1767), representing 2 distinct clinical scenarios. A total of 28 clinical features were extracted and multiple machine learning predictive models were developed for both pressure injury phenotypes. The random forest model performed best and achieved an AUC of 0.92 and 0.94 in 2 test sets, respectively. The Glasgow coma scale, a nurse-entered level of consciousness measurement, was the most important feature for both groups.

CONCLUSIONS

This model accurately predicts pressure injury development and, if validated externally, may be helpful in widespread pressure injury prevention.

Socioeconomic effects of pressure ulcer

A pressure ulcer is defined as localized ischemic skin or soft tissue damage resulting from disruption of the blood supply by pressure over the bony prominence. However, it is not just a wound that causes pain to individuals, but also a complex disease that causes socioeconomic losses. In 2019, total 30,983 patients with pressure ulcers were treated at medical institutions in Korea, and 76 billion Korean won (KRW) was spent on this treatment. Inpatient care cost amounted to 65.5 billion KRW, whereas outpatient care cost amounted to 9.8 billion KRW. The average hospitalization cost per patient was 6,696,605 KRW, and the average hospitalization period was 57.4 days, averaging 116,707 KRW per patient per day. The average outpatient care cost per patient was 421,134 KRW, and the average period in the clinic was 8.9 days, calculated at 47,428 KRW per day. The development of pressure ulcers inevitably causes socioeconomic losses and puts strain on limited medical resources; therefore, the best socioeconomic solution is prevention. Prevention has been shown to be much more efficient in cost-effective studies on treatment and prevention. Therefore, investment of more resources to prevent the development of pressure ulcers is the best solution to reduce the related socioeconomic burden.

Pressure ulcers: an overview

This article gives a general overview of pressure ulcers, with a focus on secondary care. Pressure ulcers are damage to the skin or underlying tissue as a result of pressure, friction or shearing forces. They place a significant physical, psychological and financial burden on patients and healthcare systems which will be explored. This review also covers risk assessment, classification and management of pressure ulcers in the inpatient setting.

Relationship between a pressure redistributing foam mattress and pressure injuries: An observational prospective cohort study

BACKGROUND AND PURPOSE

Pressure injuries remain a significant health care issue in various settings. The purpose of this study was to examine the relationship between a pressure redistributing foam mattress (PRFM) and the development of pressure injuries.

METHODS

This study employed an observational prospective cohort study design. We enrolled 254 participants from the intensive care unit who were at risk of developing pressure injuries. Participants were exposed to either a nonpressure redistributing foam mattress (NPRFM), which was the standard mattress used at the study site, or a PRFM made of viscoelastic, temperature-sensitive, polyurethane memory foam. The patients' assignment to either a PRFM or NPRFM was performed upon their admission, before the study eligibility screening. The relationship between the PRFM and the development of pressure injuries was studied using a logistic regression model.

RESULTS

The overall incidence of pressure injuries was 5.9% (15/254) in our study, with 1.6% (2/127) for participants who used a PRFM and 10.2% (13/127) for those using a NPRFM. After adjusting for potential confounding variables, use of a PRFM was associated with an 88% reduced risk of pressure injury development (OR = 0.12, 95% CI: 0.03, 0.56, P = 0.007). The use of a PRFM also contributed to a postponed occurrence of pressure injuries by 4.2 days on average in comparison with that of a NPRFM (P = 0.041).

CONCLUSIONS

A PRFM is associated with a significantly reduced incidence and postponed occurrence of pressure injuries. It is recommended to use a PRFM for patients at risk of developing pressure injuries.

Incidence of hospital-acquired pressure injury: A cohort study of adults admitted to public and private hospitals in Sao Paulo, Brazil

This study aimed to estimate the incidence of hospital-acquired pressure injury (PI) and its risk factors in inpatient and intensive care units of five hospitals (two public and three private) in the city of Sao Paulo, Brazil. A 6-month follow-up prospective cohort study (n = 1937) was conducted from April to September 2013. Baseline and follow-up measurements included demographic and care information, as well as risk assessments for both undernutrition (NRS-2002) and PI (Braden scale). Poisson regression with robust variance was used for data analysis. A total of 633 patients (32.60%) showed risk for PI. The incidence rate of PI was of 5.9% (9.9% in public hospitals vs 4.1% in private hospitals) and was higher in intensive care units, compared to inpatient care units (10% vs 5.7%, respectively). Risk for PI increased with age (RR = 1.05; 95% CI 1.04-1.07); was higher in in public hospitals, compared to private hospitals (RR = 4.39; 95% CI 2.92-6.61); in patients admitted for non-surgical reasons compared to those admitted for surgical reasons (RR = 1.91; 95% CI 1.12-3.27); in patients with longer hospital stays (RR = 1.04; 95% CI 1.03-1.06); high blood pressure (RR = 1.76; 95% CI 1.17-2.64); or had a risk for undernutrition (RR = 3.51; 95% CI 1.71-7.24). Higher scores in the Braden scale was associated with a decreased risk of PI (RR = 0.79; 95% CI 0.75-0.83). The results of our study indicate that 5.9% of all patients developed PI and that the most important factors that nurses should consider are: patient age, care setting, length of hospitalization, comorbidities, reason for admission and nutrition when planning and implementing PI-preventative actions.

Determination of nurses' level of knowledge on the prevention of pressure ulcers: The case of Turkey

AIM OF THE STUDY

Pressure ulcers (PUs) constitute a health issue that has a high prevalence and incidence rate in acute and long-term care, requiring long-term nursing care for treatment and prevention. Therefore, nurses should have adequate knowledge of the interventions and practices used to prevent PUs.

MATERIALS AND METHODS

This study employed a descriptive and cross-sectional design to assess the level of nurses' knowledge concerning preventive interventions for PUs. Based on data found in the literature, researchers developed a 16-question Participant Information Form (including age, gender, level of education, employed ward, and training on PUs) and used this form, along with the Turkish version of the Pressure Ulcer Prevention Knowledge Assessment Instrument (PUPKAI-T), to collect data.

RESULTS

A group of 471 nurses working in two foundation hospitals in 2018 participated in the study by completing a questionnaire. Among the participants, 44.2% worked in surgery, 21.2% in internal medicine, and 34.6% in other wards (such as intensive care, pediatrics, and the operating theater). Most of the nurses(73.5%) held a bachelor's degree, and their average work experience was 7.27 ± 7.00 years. It was determined that 69.4% of the nurses had not received in-service training relating to PUs, 55.6% did not attend lectures/conferences or read articles on the prevention of PUs, and 59.7% rated themselves as "adequate" in interventions used to prevent PUs. Based on the use of PUPKAI-T, 17 individuals (3.6%) scored equal to or more than the 60% cut-off value, and 454 individuals (96.4%) scored less than 60%. The mean level of knowledge on PUs was calculated as 11.1 ± 2.659 (range: 1-18) out of 26 questions.

CONCLUSIONS

Results of the study showed that the general level of knowledge of nurses in preventing PUs are extremely insufficient. Therefore, various strategies should be developed to increase nurses' level of knowledge on the etiology and development, classification and observation, and risk assessment of PUs, as well as on nutrition plans and preventive interventions.

A multilayer polyurethane foam dressing for pressure ulcer prevention in older hip fracture patients: an economic evaluation

OBJECTIVE

Hospital-acquired pressure ulcers (PU) have a substantial negative impact on patients and continue to impose a cost burden on hospital providers. Since the incidence of fragility fracture is growing, driven by the increase in the older population, it is expected that the overall incidence of associated complications will also increase accordingly. The aim of this economic evaluation was to determine whether the use of a multilayer, silicone-adhesive polyurethane foam dressing (ALLEVYN LIFE, Smith & Nephew, UK) alongside standard prevention (SP) for the prevention of PUs in older patients with hip fractures is a cost-effective strategy, compared with SP alone.

METHOD

A decision-analytic model was constructed to determine the incremental cost and effectiveness of the foam dressing strategy from the perspectives of the Italian and US hospital systems. We also performed one-way and probabilistic sensitivity analyses.

RESULTS

The foam dressing intervention was found to be cost saving and more effective than SP in both Italy and the US. Switching to foam dressing and standard prevention would result in an expected cost saving of €733 per patient in Italy and $840 per patient in the US, reducing the per-patient cost of treating PUs by 37-69% and 36-68%, respectively. The one-way and probabilistic sensitivity analyses demonstrate that the strategy remains dominant over a range of values of the input variables.

CONCLUSION

The foam dressing intervention is likely to be a cost-effective strategy compared with standard prevention alone.

The national cost of hospital-acquired pressure injuries in the United States

Our objective was to estimate the US national cost burden of hospital-acquired pressure injury (HAPI) using economic simulation methods. We created a Markov simulation to estimate costs for staged pressure injuries acquired during hospitalisation from the hospital perspective. The model analysed outcomes of hospitalised adults with acute illness in 1-day cycles until all patients were terminated at the point of discharge or death. Simulations that developed a staged pressure injury after 4 days could advance from Stages 1 to 4 and accrue additional costs for Stages 3 and 4. We measured costs in 2016 US dollars representing the total cost of acute care attributable to HAPI incidence at the patient level and for the entire United States based on the previously reported epidemiology of pressure injury. US HAPI costs could exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full-thickness wounds, which occupy clinician time and hospital resources. HAPIs remain a concern with regard to hospital quality in addition to being a major source of economic burden on the US health care system. Hospitals should invest more in quality improvement of early detection and care for pressure injury to avoid higher costs.

Costs and consequences of an intervention-based program to reduce hospital-acquired pressure injuries in one health district in Australia

Objectives The aims of this study were to determine the costs of hospital-acquired pressure injuries (HAPIs) in one local health district in Australia and compare the costs and consequences of an intervention-based program with current practice to reduce HAPI incidence and prevalence. Methods A retrospective cost-consequence analysis was conducted using HAPI incidence rate per occupied bed days, point prevalence rates, Australian Refined-Diagnosis Related Group (AR-DRG) costs and the costs of the program to reduce the HAPI rate. Data were analysed for two phases: preprogram implementation (1 June 2015-1 June 2016) and postprogram implementation (1 August 2016-31 July 2017). Results The HAPI intervention-based program resulted in a 51.4% reduction in the incidence of HAPI (from 1.46 per occupied bed day in 2014 to 0.71 per occupied bed day in 2017) and a 71.6% reduction in the prevalence of HAPI (from 6.7% in 2014 to 1.9% in 2017). The occurrence of HAPI added an average cost of A$3332 per episode, such that the overall program, including implementation, reduced costs by A$837387. The greatest cost reduction was due to the cessation of washable and disposable underpads. The largest contributor to the cost of HAPI prevention was for education and training regarding HAPI prevention initiatives. Conclusions The HAPI intervention-based program halved the incidence and substantially reduced the prevalence of HAPI, with a 23.1% cost saving compared with the previous approach to preventing HAPIs. What is known about the topic? HAPIs are costly to the individual, the organisation and health system. The prevention of HAPIs is a priority in Australia. There is limited research on the economic effect of HAPIs and the costs and consequences for hospitals of implementation strategies to reduce their incidence. What does this paper add? This paper informs health policy and decision makers about the costs and consequences for a local health district of a program to reduce and prevent HAPIs. This paper reports the economic effect of HAPIs, including hospital episode costs per HAPI and length of stay, on one local health district. What are the implications for practitioners? This cost-consequence analysis has shown that the program to reduce HAPIs resulted in a reduction in expenditure and positive patient outcomes. Such a program is potentially transferable to other healthcare settings.

Pressure ulcer definitions and core curricula-how does this affect wound care and the older patient?

Chronic wounds are associated with a significant patient, healthcare and financial burden and can have extensive implications for healthcare. Age is a significant risk factor for developing chronic wounds, due to physical changes in skin integrity and several age-related complex comorbidities, including poor nutrition and mobility. Pressure ulcers (PU) are a common type of chronic wound that can have a substantial impact on health-related quality of life and patient outcomes. Understanding the extent of PU harm is problematic, due to discrepancies in the definition, recording and reporting of PUs on both a local and national level. Education and training are central to ensuring the risk factors associated with PU development are recognised, and a consistent and coherent structure to the definition, measurement and reporting of PUs across the NHS is developed.

Nutritional management of older hospitalised patients with pressure injuries

This cross-sectional, multicentre study was conducted in hospitals to investigate nutritional interventions conducted in patients aged 70 years or older with (risk of) pressure injuries. A total of 1412 patients from 33 hospitals with 208 wards participated in the study. A standardised questionnaire was used to collect demographic data and data on care dependency, malnutrition risk, risk for/prevalence of pressure injuries, and nutritional interventions. Data analyses were conducted by using descriptive statistics, chi-square tests, or independent t-tests. According to the Braden Scale, 678 (48.0%) of the patients were at risk of developing pressure injuries, and 71 patients (5.0%) had at least one pressure injury (assessed by skin inspection). The most frequently conducted nutritional interventions in patients with pressure injuries were providing support during mealtimes (50.7%), food specifically desired by the patient (40.8%), and conducting a malnutrition screening (39.4%). One quarter of the patients with pressure injuries were referred to a dietitian. The provision of an energy-enriched/protein-enriched diet (18.3%), energy-enriched/protein-enriched snacks (12.7%), or oral nutritional supplements (8.5%) was rare. Nutritional care in older patients with risk of pressure injuries is suboptimal. Health care professionals need to raise awareness regarding the importance of nutrition in the management of patients with pressure injuries.

The association between major complications of immobility during hospitalization and quality of life among bedridden patients: A 3 month prospective multi-center study

Purpose

To describe the association between major complications of immobility (pressure ulcer, pneumonia, deep vein thrombosis and urinary tract infection) during hospitalization and the patients’ health-related quality of life after discharge.

Methods

The data were obtained from a multi-center study conducted in 2015. Complications of immobility during hospitalization was measured by case report form and quality of life after discharge was measured using the EQ-5D scale by telephone interview. Multilevel mixed-effects models were used to explore the association of complications and responses in the EQ-5D dimensions after controlling for important covariates.

Results

Among the 20,515 bedridden patients, 2,601(12.72%) patients experienced at least one of the major complications of immobility during hospitalization, including pressure ulcer (527, 2.57%), deep vein thrombosis (343, 1.67%), pneumonia (1647, 8.16%), and urinary tract infection (265, 1.29%). Patients with any of the four complications during hospitalization reported more problems in all EQ-5D dimensions except for pain/discomfort, and had lower mean EQ-VAS scores than those without any complications. The four complications all showed significant associations with the proportion of reported problems in certain dimensions after adjustment for confounding variables.

Conclusions

Major complications of immobility were significantly associated with reduced health related quality of life. Prevention of complications is critical to reduce the burden of decreased quality of life for bedridden patients.