PROTECT - Trial: A cluster RCT to study the effectiveness of a repositioning aid and tailored repositioning to increase repositioning compliance

Nurses' Clinical Decision-Making About Pressure Injury Prevention in Hospital Settings: A Scoping Review

AIM

To systematically explore research on nurses' clinical decision-making and factors influencing pressure injury prevention in hospitalised patients.

DESIGN

Scoping review.

DATA SOURCES

Medline full text, Cumulative Index to Nursing and Allied Health Literature Plus with full text, and Scopus.

METHODS

Arksey and O'Malley's five-step framework guided this scoping review. Studies published prior to 11 July 2024 were included.

RESULTS

Thirty-eight studies were included. The factors influencing nurses' decision-making in pressure injury prevention included: 'support systems', 'knowledge and attitudes', 'barriers to implementing prevention practices' and 'risk assessment tools and clinical judgement'. Limited research was conducted on nurses' clinical decision-making about implementation of pressure injury prevention interventions.

CONCLUSION

More research on nurses' clinical decision-making related to pressure injury prevention is needed to enhance education, support effective care and reduce the incidence of pressure injuries.

IMPACT

Nurses recognise the importance of preventing pressure injuries, however implementation of pressure injury prevention interventions are inconsistent, and pressure injuries remain common in hospitals. Limited research exists on the processes nurses use to make clinical decisions about pressure injury prevention for hospitalised adults at risk of pressure injury.

REPORTING METHOD

This scoping review adhered to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The clinical applicability of sensor technology with body position detection to combat pressure ulcers in bedridden patients

INTRODUCTION

Pressure Ulcers (PUs) are a major healthcare issue leading to prolonged hospital stays and decreased quality of life. Monitoring body position changes using sensors could reduce workload, improve turn compliance and decrease PU incidence.

METHOD

This systematic review assessed the clinical applicability of different sensor types capable of in-bed body position detection.

RESULTS

We included 39 articles. Inertial sensors were most commonly used (n = 14). This sensor type has high accuracy and is equipped with a 2-4 hour turn-interval warning system increasing turn compliance. The second-largest group were piezoresistive (pressure) sensors (n = 12), followed by load sensors (n = 4), piezoelectric sensors (n = 3), radio wave-based sensors (n = 3) and capacitive sensors (n = 3). All sensor types except inertial sensors showed a large variety in the type and number of detected body positions. However, clinically relevant position changes such as trunk rotation and head of bed elevation were not detected or tested.

CONCLUSION

Inertial sensors are the benchmark sensor type regarding accuracy and clinical applicability but these sensors have direct patient contact and (re)applying the sensors requires the effort of a nurse. Other sensor types without these disadvantages should be further investigated and developed. We propose the Pressure Ulcer Position System (PUPS) guideline to facilitate this.

The practice and facilitators of, and barriers to, implementing individualized repositioning frequency: A national cross-sectional survey of critical care nurses

AIMS

To understand the clinical status of implementing individualized repositioning frequency-and its barriers and facilitators-among critical care nurses in China, in view of developing targeted intervention strategies and improving guideline implementation.

DESIGN

A cross-sectional survey.

METHODS

A self-report questionnaire was developed with reference to the Theoretical Domains Framework and administered to critical care nurses in 15 hospitals across eastern, southern, western, northern, and central geographical areas of China from 20 February 2023 to 16 March 2023. Data were collected for personal demographics, clinical practice status, and from Likert-type responses about barriers to and facilitators of implementing individualized repositioning frequency.

RESULTS

In total, 574 effective questionnaires were collected. Only 3.8 % of respondents reported that their hospital/ward uses an individualized repositioning frequency rule. Six facilitator domains identified were: social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; and intentions. Seven barrier domains were: knowledge; skills; goals; memory, attention and decision processes; environmental context and resources; social influences; and behavioral regulation. Inferential analysis showed that critical care nurses who had higher degrees, more years of work, more environmental support, and more nursing experience were prone to being more positive in response to the implementation of individualized repositioning frequency.

CONCLUSION

The clinical practice status of implementing individualized repositioning frequency among critical care nurses in China is unsatisfactory. Implementation is essential but complex and is influenced by several factors. Theory-based suggestions for improving this situation are provided on the basis of identified barriers.

Effect of various repositioning regimens on pressure wound ulcer occurrence in at-risk adult persons without existing pressure wound ulcers: A meta-analysis

Meta-analysis research was implemented to appraise the effect of various repositioning regimens (RRs) on pressure wound ulcer (PWU) occurrence in at-risk adult persons without existing PWUs. Inclusive literature research till April 2023 was done and 1197 interconnected researches were revised. The 15 picked researches, enclosed 8510 at-risk adult persons without existing PWUs persons were in the utilised researchers' starting point, 1002 of them were utilising repositioning, 1069 were control, 3443 were utilising 2-<4 h repositioning and 2994 were utilising 4-6 h repositioning. Odds ratio (OR) and 95% confidence intervals (CIs) were utilised to appraise the consequence of various RRs on PWU occurrence in at-risk adult persons without existing PWUs by the dichotomous approach and a fixed or random model. Repositioning had significantly lower PWU (OR, 0.49; 95% CI, 0.32-0.73, p < 0.001) compared to control in at-risk adult persons without existing PWUs persons. 2-<4 h repositioning had significantly lower PWU (OR, 0.62; 95% CI, 0.42-0.90, p = 0.01) compared to 4-6 h repositioning in at-risk adult persons without existing PWUs persons. Repositioning had significantly lower PWU compared to control in at-risk adult persons without existing PWU persons. 2-<4 h repositioning had significantly lower PWU compared to 4-6 h repositioning in at-risk adult persons without existing PWUs persons. However, caution needs to be taken when interacting with its values since there was a low sample size of some of the chosen research found for the comparisons in the meta-analysis.

Comparison of Ventilator-Associated Pneumonia and Surgical Site Infection between Two Methods of Tracheostomy

Objective

To compare the incidence of ventilator-associated pneumonia (VAP) and surgical site infection (SSI) between percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST).

Methods

Data on 487 patients undergoing tracheostomy between 1st January 2014 and 30th September 2020 were reviewed. Patients were divided according to the surgical techniques. Clinical characteristics and postoperative care were compared to explore the risk factors for SSI and VAP. All tracheostomies were performed by intensivists who had completed at least ten tracheostomies. ST was performed using standard techniques. PDT was performed according to a modification technique described by Ciaglia. All procedures were performed at the bedside in the ICU.

Results

Of all, 344 patients (70.6%) were men and 143 (29.4%) were women, and the mean age was 56 years (standard derivation [SD] 12 years). Two hundred and sixty-six patients (54.6%) received PDT, and 221 (45.4%) received SY. Patients in the PDT group had a significantly lower rate of SSI (3.4% vs. 8.5%, P = 0.01) compared with the ST group. Multivariate analysis revealed that comorbidities (P = 0.003), surgical type (P = 0.01), and cluster nursing (P < 0.001) were independent risk factors for SSI; age (P = 0.005), comorbidities (P < 0.001), smoking (P = 0.008), and cluster nursing (P = 0.01) were independent risk factors for VAP.

Conclusion

PDT significantly reduces the risk of SSI. Proper care should be administrated in patients with one or more risk factors of SSI or VAP to prevent the occurrence of complications.

The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review

BACKGROUND

Incontinence-associated dermatitis is a common, under-recognized painful skin condition associated with poorer quality of life, increased nurse workloads, and costs.

OBJECTIVE

To systematically review economic evidence for the prevention and treatment of incontinence-associated dermatitis.

DESIGN

Systematic review of quantitative research.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane Library, York Centre for Reviews and Dissemination database, Econlit, Tufts' Cost-Effectiveness Analysis Registry, and Web of Science.

REVIEW METHODS

A comprehensive search for studies on resource use (costs), health outcomes, and cost-effectiveness of interventions for incontinence-associated dermatitis was conducted. Screening, data extraction, and initial quality assessment were conducted independently by two reviewers, with disagreements/queries regarding quality settled through consensus with the larger team. Quality evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist and results narratively arranged.

FINDINGS

Seventeen studies (10 for prevention, one for treatment and six for both prevention and treatment) included. All studies measured resource use from a healthcare provider perspective; 14 quantified resources in monetary terms. Considerable variation existed in the resource use data primarily due to differences in the type of resources counted, selected time horizons, valuation methods, and reporting approaches. Ten studies provided evidence of their intervention to be cost saving (or at least cost avoiding). Five studies on barrier products provided evidence to be cost saving: three for prevention, one for treatment, and one for both prevention and treatment. Two studies of cleanser and barrier products provided evidence to be cost saving for the prevention and treatment of incontinence-associated dermatitis. One study found a cleanser to be a cost saving preventative intervention. One bowel management system was found to be cost saving over time only, and one nurse education intervention was found to be cost saving for preventing and treating incontinence-associated dermatitis. One barrier product was found to be cost-effective for preventing and treating the condition. Finally, one study found a cleanser and barrier product was time saving for prevention. None of the studies incorporated a multi-attribute quality of life measure; however, two studies included person-reported outcome measures for pain. A narrow range of resources (mainly products) were considered, and there was limited information on how they were counted and valued. Analyses relating to heterogeneity among patients/hospital wards or health facilities and uncertainty were lacking.

CONCLUSIONS

Barrier products are possibly a more cost-effective treatment than others; however, this evidence lacks certainty. Structured health economic evaluations are required for a reliable evidence-base on the interventions for incontinence-associated dermatitis.

TWEETABLE ABSTRACT

Most incontinence-associated dermatitis studies lack person-reported outcomes, costs beyond product/staff time, and economic evaluation.

Repositioning Practice of Bedridden Patients: An Evolutionary Concept Analysis

Introduction

Repositioning practice is an essential pressure ulcer prevention intervention that has emerged in the history of nursing. Numerous terms are employed to indicate its meaning, such as turning, positioning, or posturing. However, there is no available analysis that distinguishes these terms or analyzes repositioning practice attributes.

Objective

To analyze repositioning practice as a concept of bedridden patients in hospitals by combining methods from Foucault's archeology of knowledge and Rodger's concept analysis.

Concept Description

Repositioning practice passes through three eras: classical, modern, and research. The repositioning practice is “turn a bedridden patient in a harmonized way and ends with anchor and documentation.” The analysis concludes seven attributes for the repositioning practice: pre-turn, assessment, turn, harmonization, anchor, documentation, and time. The analysis assumes bedridden patients, and assigned nurses on duty are the antecedents. Moreover, the main consequence is pressure ulcer prevention, while patient safety and quality of care are the secondary consequences.

Discussion

Repositioning practice understanding has grown with time. Each era has added to or removed from nursing's understanding for repositioning practice until it appears as it now. The current analysis expects further development in repositioning practice understanding and applications.

Conclusion

Repositioning practice is an important nursing intervention and has shown a dynamic movement over history. It is expected that this dynamic will continue in the future.

E-Health Decision Support Technologies in the Prevention and Management of Pressure Ulcers: A Systematic Review

Pressure ulcers are problematic across clinical settings, negatively impacting patient morbidity and mortality while resulting in substantial costs to the healthcare system. E-health clinical decision support technologies can play a key role in improving pressure ulcer-related outcomes. This systematic review aimed to assess the impact of electronic health decision support interventions on pressure ulcer management and prevention. A systematic search was conducted in PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane. Nineteen articles, published from 2010 to 2020, were included for review. The findings of this review showed promising results regarding the usability and accuracy of electronic health decision support tools to aid in pressure ulcer prevention and management. Evidence indicated improved clinician adherence to pressure ulcer prevention practices and decreased healthcare costs postimplementation of an electronic health decision support intervention. However, the studies included in this review did not consistently show reductions in pressure ulcer prevalence, incidence, or risk. Most of the articles included in the review were limited by small sample sizes drawn from single hospitals or long-term care homes. More high-quality studies are needed to determine the types of electronic health decision support tools that can drive sustainable improvements to patient outcomes.

Repositioning for preventing pressure ulcers: a systematic review and meta-analysis

Objective:

The aim of this systematic review was to assess the effects of different repositioning regimens on pressure ulcer (PU) incidence in at-risk adult individuals without existing PUs.

Method:

Using systematic review methodology, randomised controlled trials (RCTs), including cluster-RCTs, prospective non-RCTs, pre–post-studies and interrupted-time-series studies were considered. Specifically explored was the impact of the frequency of repositioning, use of repositioning systems and use of turning teams. The search was conducted in January 2019, using PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases. Data were extracted using a pre-designed extraction tool and analysis was undertaken using RevMan.

Results:

A total of 530 records were returned, of which 16 met the inclusion criteria. Half of studies were conducted in intensive care units (50%). The mean sample size was 629±604 participants. Frequency of repositioning was explored in nine studies. PU incidence was 8% (n=221/2834) for repositioning every 2–3 hours, versus 13% (n=398/3050) for repositioning every 4–6 hours. The odds ratio (OR) was 0.75 (95% confidence interval (CI): 0.61–0.90, p=0.03), suggesting that there is a 25% reduction in the odds of PU development in favour of more frequent repositioning. Use of a repositioning system was explored in three studies. PU incidence was 2% (17/865) for the repositioning system, versus 5.5% (51/926) for care without using the repositioning system. The OR was 0.26 (95% CI: 0.05–1.29, p=0.10); this finding was not statistically significant. Use of a turning team was explored in two studies. PU incidence was 11% (n=22/200) with use of a turning team versus 20% (n=40/200) for usual care. The OR was 0.49 (95% CI: 0.27–0.86, p=0.01) suggesting that there is a 51% reduction in the odds of PU development in favour of use of a turning team. Using GRADE appraisal, the certainty of the evidence was assessed as low.

Conclusion:

The results of this systematic review indicate that more frequent repositioning and use of a turning team reduce PU incidence. However, given the low certainty of evidence, results should be interpreted with caution.

Positioning immobile critically ill patients who are at risk of pressure injuries using a purpose-designed positioning device and usual care equipment: An observational feasibility study

The prevalence of pressure injuries in the intensive care unit (ICU) setting is high with rates ranging from 13.1% to 45.5%. Evaluation of interventions to prevent pressure injuries should be informed by preliminary research to identify factors that should be considered during the design of future trials. The study objectives were to evaluate the process of participant recruitment and monitoring in the ICU; measure the maintenance of body angle (in the side-lying lateral tilt position) and head and neck alignment angle (in the supine position) among immobile critically ill patients when using a purpose-designed positioning device and usual care equipment, and; ascertain the time required to position patients with the purpose-designed positioning device and the usual care equipment. A prospective, observational, feasibility study was conducted in an ICU in Victoria, Australia. The sample was immobile critically ill adults at high-risk of developing pressure injuries. The usual care interventions were pillows, foam wedges, and rolled towels, and the intervention device was the Z-Flo Fluidized Positioner. The body angle and head and neck alignment were measured on six occasions (at baseline, 1 hour, and 2 hours). The time required for positioning was also measured. The sample was predominately male (n = 5, 62%) with a mean age of 59 years. The majority of patients (n = 106, 92.2%) were not immobile and therefore were ineligible to participate. A total of 48 turning and positioning interventions were observed. For the side-lying lateral tilt position, the degree of difference from baseline to 2 hours was no more than three degrees for all the devices (the Fluidized Positioner 25°-26°, the foam wedge 29°-27°, and the pillow 23°-21°). For the head and neck position, the degree of difference from baseline to 2 hours was the greatest for the pillow and rolled towel (78°-71°, a difference of 7°) and the pillow alone (79°-74°, a difference of 5°). The degree of difference was the lowest for the Fluidized Positioner (84°-86°, a difference of 2°). Future research to evaluate positioning equipment in the ICU should consider patient eligibility characteristics, particularly immobility. The conduct of preliminary studies to inform the design of larger pressure injury prevention trials is recommended.

Pressure ulcer Cat. II-IV incidence on the CuroCell S.A.M. PRO powered reactive air support surface in a high-risk population: A multicentre cohort study in 12 Belgian nursing homes

The primary objective was to study pressure ulcer (PU) category II-IV (including suspected deep tissue injury and unstageable PUs) cumulative incidence and PU incidence density, in a 30day observation period, associated with the use of the CuroCell S.A.M. PRO powered reactive air support surface in nursing home residents at risk for PU development. Secondary objectives were to study (a) PU category I cumulative incidence and PU incidence density and (b) user (caregivers and residents) experiences and perceptions of comfort associated with the use of the support surface under study. A multicentre cohort study was set up in 37 care units of 12 Belgian nursing homes. The sample consisted of 191 residents at risk of PU development (Braden score ≤ 17). The cumulative PU incidence was 4.7% (n = 9). The PU incidence density was 1.7/1000 observation days (9 PU/5370 days). The experience and perceptions of comfort analysis revealed that the CuroCell S.A.M. PRO powered reactive air support surface was comfortable for daily use. The mode of action and the quietness of the pump function had a positive impact on sleep quality. Patient comfort and sleep quality are essential criteria in the selection of a support surface.