African Americans show increased risk for pressure ulcers: A retrospective analysis of acute care hospitals in America

Socio-economic and environmental factors associated with community-acquired pressure injuries: A mixed method study

AIMS

To: (1) report on the prevalence of community-acquired pressure injuries (CAPIs) in patients admitted into the acute care setting; (2) examine the socio-economic and home environment associated with CAPIs; and (3) understand the challenges of caring for patients with CAPIs at home.

METHODS

This mixed-method study recruited patients admitted with CAPIs in the acute care hospital between March 2021 to June 2022. The hospital's pressure injury (PI) database was used to screen patients admitted with CAPIs. A purposive sample of CAPI patients and their caregivers participated in this study. A cross-sectional survey study was first performed to examine the prevalence of CAPIs and the socio-economic and home environment factors. Semi-structured interviews were conducted to understand the caregivers' challenges in caring for patients with CAPIs at home.

RESULTS

The CAPI prevalence was reported at 1.1 % during the study period (1039 had CAPIs out of 97 912 patients admitted to the hospital). A total of 70 caregivers and patients consented to participate in the study. The mean age of patients was 84.2 (SD = 10.4) years old; 68.6 % (n = 48) were females. Majority presented with a deep tissue injury (DTI) (37.1 %; n = 26) or unstageable PI (31.4 %; n = 22). More than half of the patients had alternating air mattresses at home (54.3 %; n = 38), and only 10 % (n = 7) had positioning wedges and used a sliding sheet for turning. The mean age of the caregivers was 43.4 years old (SD = 13.1), and 84.3 % (n = 59) were female. Continuous data were summarised using means and standard deviations, and categorical data were summarised using frequencies and percentages. Logistic regression found no significant socio-demographic and clinical predictors of patients having PI stages 2, 3, and 4 compared to patients with DTI and unstageable PI. Challenges to caring for PI at home included high financial burden, physical limitations, and personal challenges in CAPIs management.

CONCLUSION

CAPIs are prevalent among older patients admitted to the acute care setting. Understanding the influence of socio-economic factors is crucial for developing comprehensive strategies to mitigate the occurrence and impact of PIs. Ongoing support and education to the caregivers in the community is essential to address the reported challenges in PI care.

Current Perspectives on Pressure Injuries in Persons with Dark Skin Tones from the National Pressure Injury Advisory Panel

BACKGROUND

Pressure injury (PI) development is multifactorial. In patients with dark skin tones, identifying impending PIs by visual skin assessment can be especially challenging. The need for improved skin assessment techniques, especially for persons with dark skin tones, continues to increase. Similarly, greater awareness of the need for inclusivity with regard to representation of diverse skin colors/tones in education materials is apparent.

OBJECTIVE

To provide current perspectives from the literature surrounding skin assessment and PI development in patients with dark skin tones.

METHODS

The following elements will be discussed through the lens of skin tone: (1) historical perspectives of PI staging from the National Pressure Injury Advisory Panel, (2) epidemiology of PI, (3) anatomy and physiology of the skin, (3) skin tone assessment and measurement, (4) augmented visual assessment modalities, (5) PI prevention, (6) PI healing, (7) social determinants of health, and (8) gaps in clinician education.

CONCLUSIONS

This article highlights the gap in our clinical knowledge regarding PIs in patients with dark skin tones. Racial disparities with regard to PI development and healing are especially clear among patients with dark skin tones. Skin tone color assessment must be standardized and quantifiable in clinical education, practice, and research. This work is urgently needed, and support from private and governmental agencies is essential.

Pressure Ulcer Diagnosis Is Associated with Increased Mortality in Patients with End-Stage Renal Disease: A Retrospective Study

Pressure ulcers are associated with multiple comorbidities and annually affect approximately 3 million Americans, directly accounting for approximately 60,000 deaths per year. Because patients with end-stage renal disease (ESRD) are known to present with unique factors which impair wound healing, pressure ulcers diagnosed in ESRD patients might independently increase the risk of mortality. To investigate the association between pressure ulcer diagnosis and mortality risk in the ESRD population, a retrospective analysis of the United States Renal Data System (USRDS) database was performed. The records of 1,526,366 dialysis patients who began therapy between 1 January 2005 and 31 December 2018 were included. Our analysis showed that the diagnosis of pressure ulcers in this population was independently associated with mortality even after controlling for confounding factors (p < 0.001). A Kaplan-Meier survival analysis demonstrated reduced survival in patients with a pressure ulcer diagnosis compared to those without a pressure ulcer diagnosis. These results establish pressure ulcers as a significant independent risk factor for mortality, as well as suggesting several comorbidities as potential risk factors for pressure ulcers in the ESRD population.

Breakthrough treatments for accelerated wound healing

Skin injuries across the body continue to disrupt everyday life for millions of patients and result in prolonged hospital stays, infection, and death. Advances in wound healing devices have improved clinical practice but have mainly focused on treating macroscale healing versus underlying microscale pathophysiology. Consensus is lacking on optimal treatment strategies using a spectrum of wound healing products, which has motivated the design of new therapies. We summarize advances in the development of novel drug, biologic products, and biomaterial therapies for wound healing for marketed therapies and those in clinical trials. We also share perspectives for successful and accelerated translation of novel integrated therapies for wound healing.

Assessing the Correlation Between Patient-Specific Characteristics and Braden Pressure Injury Risk Score at a Suburban Tertiary Hospital in Nigeria

Background and objective Pressure injury (PI) is a frequent complication of hospital admissions, and it increases healthcare costs, morbidity, and mortality. This study aimed to use the Braden scale to assess the PI risk among hospitalized patients without PI and determine its association with patient-specific factors. Methods A cross-sectional study was conducted at a suburban tertiary hospital involving a total of 211 hospitalized patients recruited during the study period (October 2022). Patients were assessed using the Braden scale and their sociodemographic data were also recorded. Data analysis was performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). Results The mean age of the patients was 41.8 ±23.0 years and 54.0% of the patients were females. The average Braden score of the patients was 19.01 ±3.42, and more than half (58.3%) of the patients showed no risk while only 0.9% of the patients had a severe risk of PI. There was a statistically significant association between PI risk and patients' age (r=-0.353, R=12.5%, p<0.001), pre-admission occupation (F=10.290, p<0.001) as well as the ward of admission (F=11.915, p<0.001). However, gender and social support were not significantly associated. Conclusion The age, pre-admission occupation, and ward of admission of patients were found to be significantly associated with the risk of developing PI. It is recommended that more resources be channeled toward preventing PI among high-risk patients in resource-limited settings.

Racial Disparities and Pressure Injuries Among Hospitalized Patients

OBJECTIVE

To describe the demographic factors, hospitalization-related factors, comorbid states, and social determinants of health among racial groups in a sample of patients with a primary or secondary diagnosis of pressure injury (PI) admitted to New Jersey hospitals during the year 2018.

METHODS

Researchers conducted a retrospective analysis of the Health Care Utilization Project's 2018 New Jersey State Inpatient Database. Patients with a primary or secondary diagnosis of PI (sacrum, buttocks, or heels; N = 17,781) were included in the analytic sample. Analysis compared patients who identified as Black (n = 3,515) with all other racial groups combined (n = 14,266).

RESULTS

A higher proportion of Black patients were admitted for a PI (P < .001) and had higher proportions of stage 4 PIs (P < .001) but a lower proportion of stage 1 PIs (P < .001). Higher proportions of Black patients were younger, resided in lower income communities, and identified Medicaid as their primary payor source.

CONCLUSIONS

Results highlight the racial disparities that exist among patients with PIs in this diverse state and may represent a much larger problem. Clinical research examining the impact of skin tone rather than by racial group is needed. The impact of racial disparities on social determinants of health with regard to PIs remains largely unknown, but its importance cannot be underestimated.

The panniculus carnosus muscle: a missing link in the chronicity of heel pressure ulcers?

Chronic and recurring pressure ulcers (PUs) create an unmet need for predictive biomarkers. In this work, we examine the panniculus carnosus, a thin cutaneous muscle, traditionally considered vestigial in humans, and ask whether the panniculus may play a role in the chronicity and reinjury of heel PUs. To determine whether humans have a panniculus muscle layer at the heel, we dissected eight cadavers. To assess the influence of the panniculus layer on PU, we performed computational simulations of supine weight bearing. Finally, we assessed panniculus regeneration in fluorescent mice. Results show a panniculus layer present in all cadavers examined. Simulations show a thin layer of panniculus muscle causes a dramatic decrease in the volume of soft tissue experiencing high strain and stress, compared to a heel without a panniculus. Importantly, in the mouse model, the panniculus fails to regenerate after PU, even when other cutaneous layers had fully regenerated. Our work shows that the panniculus is able to redistribute load around the heel bone, which might allow it to prevent PUs. Moreover, it is highly susceptible to incomplete regeneration after PU. Poor panniculus regeneration after PU might be a predictive anatomical biomarker for recurrence, and this biomarker should be evaluated prospectively in future clinical trials.

Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients With COVID and ARDS

BACKGROUND

During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS.

OBJECTIVES

To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS.

METHODS

This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist.

RESULTS

As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001).

CONCLUSION

The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2.

A randomized controlled trial to compare the interface pressures of alternating pressure overlay with gel pad versus gel pad alone during prolonged surgery

INTRODUCTION

Prolonged surgery is a known risk of pressure ulcer formation. Pressure ulcers affect the quality of life, are a significant cause of morbidity and mortality, and pose a burden on the healthcare system. This study aimed to compare the effectiveness of an alternating pressure (AP) overlay with Gel pad against the Gel pad in reducing interface pressure (IP) during prolonged surgery.

METHODS

A total of 180 participants from a tertiary hospital were randomized to AP overlay with Gel pad group (n = 90) and Gel pad group (n = 90). Patients were placed supine on the pressure redistributing surfaces, and IP data under the sacrum and ischial tuberosities were collected at an interval of 30 min from 0 min up to a maximum of 570 min.

RESULTS

Based on data from 133 participants, the average IPs during all the deflation cycles of the AP overlay (with Gel pad) were significantly lower than the average continuous IP recorded for Gel pad throughout the measuring period (p < 0.001). Only three patients (2.26% of study participants) - Gel pad group (n = 2; 2.99%) and AP overlay with Gel pad group (n = 1; 1.52%) developed post-operative pressure ulcer (p = 0.5687).

CONCLUSIONS

The lower IP during deflation cycles of the AP overlay (with Gel pad) suggests its potential effectiveness in preventing pressure ulcer formation in patients undergoing prolonged surgery. The prevention and reduction of pressure ulcers will have a considerable impact on the improved quality of life and cost savings for the patient. The study findings may facilitate the formulation of policies for preventing pressure ulcer development in the perioperative setting.

Validation of two case definitions to identify pressure ulcers using hospital administrative data

OBJECTIVE

Pressure ulcer development is a quality of care indicator, as pressure ulcers are potentially preventable. Yet pressure ulcer is a leading cause of morbidity, discomfort and additional healthcare costs for inpatients. Methods are lacking for accurate surveillance of pressure ulcer in hospitals to track occurrences and evaluate care improvement strategies. The main study aim was to validate hospital discharge abstract database (DAD) in recording pressure ulcers against nursing consult reports, and to calculate prevalence of pressure ulcers in Alberta, Canada in DAD. We hypothesised that a more inclusive case definition for pressure ulcers would enhance validity of cases identified in administrative data for research and quality improvement purposes.

SETTING

A cohort of patients with pressure ulcers were identified from enterostomal (ET) nursing consult documents at a large university hospital in 2011.

PARTICIPANTS

There were 1217 patients with pressure ulcers in ET nursing documentation that were linked to a corresponding record in DAD to validate DAD for correct and accurate identification of pressure ulcer occurrence, using two case definitions for pressure ulcer.

RESULTS

Using pressure ulcer definition 1 (7 codes), prevalence was 1.4%, and using definition 2 (29 codes), prevalence was 4.2% after adjusting for misclassifications. The results were lower than expected. Definition 1 sensitivity was 27.7% and specificity was 98.8%, while definition 2 sensitivity was 32.8% and specificity was 95.9%. Pressure ulcer in both DAD and ET consultation increased with age, number of comorbidities and length of stay.

CONCLUSION

DAD underestimate pressure ulcer prevalence. Since various codes are used to record pressure ulcers in DAD, the case definition with more codes captures more pressure ulcer cases, and may be useful for monitoring facility trends. However, low sensitivity suggests that this data source may not be accurate for determining overall prevalence, and should be cautiously compared with other prevalence studies.

Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis

Background:

Historically, complication rates after pressure ulcer reconstruction utilizing flap coverage have been high. Patients undergoing operations for pressure ulcer coverage typically have multiple risk factors for postoperative complications. The purpose of this study was to examine a large patient series in the pressure ulcer population to uncover objective evidence of the linkage between risk factors and outcomes after flap coverage.

Methods:

This study was a retrospective chart review of patients who underwent flap reconstruction for a pressure ulcer between 1997 and 2015. The characteristics of patients were analyzed to determine those who had complications such as pressure ulcer recurrence, wound dehiscence, and wound infection.

Results:

All patients (N = 276) underwent flap coverage of their pressure ulcers. The overall complication rate was 58.7% (162 patients). Wound dehiscence was the most common complication (31.2%), and the pressure ulcer recurrence rate was 28.6%. Multivariate regression for pressure ulcer recurrence revealed that body mass index <18.5 [relative risk (RR) 3.13], active smoking (RR 2.33), and ischial pressure ulcers (RR 3.46) were independent risk factors for pressure ulcer recurrence. Ischial pressure ulcers (RR 2.27) and preoperative osteomyelitis (RR 2.78) were independent risk factors for wound dehiscence. Diabetes was an independent risk factor for wound infection (RR 4.34).

Conclusions:

Our retrospective analysis revealed numerous factors that are associated with high rates of major postoperative complications. Risk factors must be taken into account when offering flap coverage, and risk-reducing strategies must be implemented in patients before pressure ulcer reconstruction.

Imaging mass spectrometry for assessing cutaneous wound healing: analysis of pressure ulcers

Imaging mass spectrometry (IMS) was employed for the analysis of frozen skin biopsies to investigate the differences between stage IV pressure ulcers that remain stalled, stagnant, and unhealed versus those exhibiting clinical and histological signs of improvement. Our data reveal a rich diversity of proteins that are dynamically modulated, and we selectively highlight a family of calcium binding proteins (S-100 molecules) including calcyclin (S100-A6), calgranulins A (S100-A8) and B (S100-A9), and calgizzarin (S100-A11). IMS allowed us to target three discrete regions of interest: the wound bed, adjacent dermis, and hypertrophic epidermis. Plots derived using unsupervised principal component analysis of the global protein signatures within these three spatial niches indicate that these data from wound signatures have potential as a prognostic tool since they appear to delineate wounds that are favorably responding to therapeutic interventions versus those that remain stagnant or intractable in their healing status. Our discovery-based approach with IMS augments current knowledge of the molecular signatures within pressure ulcers while providing a rationale for a focused examination of the role of calcium modulators within the context of impaired wound healing.

A traditional Chinese herbal formula improves pressure ulcers in paraplegic patients: A randomized, parallel-group, retrospective trial

In this study, the efficacy of a novel Chinese herbal formula, cure rot and flat sore ointment (CRFSO), in the management of stage IV pressure ulcers, and the effect of simultaneous comprehensive rehabilitation in improving the outcome were evaluated. A total of 35 paraplegic patients with stage IV pressure ulcers who underwent reconstruction and inpatient rehabilitation from January 2004 to September 2010 were included in the study. Arnebia root oil (ARO) was used on 16 patients with 11 ulcers (stage IV). The remaining 19 patients with 20 ulcers (stage IV) received a traditional Chinese herbal formula (CRFSO). After 28 days of treatment, the wound healing results, in particular, the healing rate, effectiveness rate, improvement rate and no response rate were evaluated. Six patients from the ARO group sought other types of therapy due to their own consideration of poor efficacy. After 28 days of treatment, the wound healing result and no response rate demonstrated a statistically significant difference (P<0.005) between the two groups, suggesting that the novel Chinese herbal formula is an effective treatment for pressure sores in paraplegic patients. All outcome variables demonstrated significant improvement in the CRFSO group compared with the ARO group after 28 days of treatment, with a higher healing rate (85% in the CRFSO group and 45.45% in the ARO group) and lower no response rate (5% in the CRFSO group and 18.18% in the ARO group). The traditional Chinese herbal formula improved pressure sores in paraplegic patients effectively and inpatient rehabilitation was also significantly improved.

Evaluation of the incidence of pressure ulcers using hill-rom versacare surfaces

OBJECTIVE

This study was conducted to: (1) determine the clinical effectiveness of a low-air-loss surface, VersaCare P500, in the prevention of pressure ulcers in surgical patients; (2) determine differences in the adjusted Braden scores between those using VersaCare and VersaCare P500 mattress surfaces; and (3) explore the demographic and therapeutic factors associated with the risk of skin breakdown as measured by Braden score.

DESIGN

An open label quasi-experimental clinical trial was conducted.

SETTING

A 540-bed acute care hospital.

PATIENTS

A sample of 127 surgical patients admitted for elective orthopedic or neurologic surgery participated in the study.

MAIN OUTCOME MEASURES

Decreased pressure ulcers.

RESULTS

The sample was composed of 51 (51.5%) Hispanics, 38 (38.4%) Blacks, and 10 (10.1%) Whites. Both groups were not different in their demographic and therapeutic characteristics except with regard to their total number of bed-confinement days (t = -2.225; P = .028). Multivariate analysis demonstrated that only Black race (β = -.225; P = .03), days of bed confinement (β = -.257; P = .016), and bed type (β = .257; P = .013) were independently associated with skin integrity.

CONCLUSION

The authors' findings suggest that the use of mircroclimate performance mattresses is associated with higher Braden scores, indicating a possible benefit with regard to protecting skin integrity and decreasing the risk of skin breakdown. Blacks were more likely to have lower Braden scores and "days of bed confinement" were negatively associated with the Braden score.