Evidence-based practice enhances patient outcomes: Early pressure ulcer detection with biocapacitance technology among critically ill patients

BACKGROUND

In pressure ulcers (PUs), significant tissue damage often develops beneath the skin before any visual or tactile symptoms manifest. The breakthrough technology of the SEM Scanner identifies localized micro-edema that forms at tissue depths of several millimeters up to 4 cm. This empowers critical care nurses to implement proactive preventive measures.

PURPOSE

To compare the effectiveness of the SEM scanner and Modified Cubbin and Jackson (MCJ) Scale risk assessment tool in predicting PU among immobile patients in Intensive Care Unit (ICU).

METHODS

A descriptive comparative, longitudinal study was carried out in ICU of Government Hospitals in Bahrain. Two independent raters blindly evaluated risk of PU against MCJ Scale, and a trained critical care nurse used SEM scanner.

RESULTS

SEM scanner demonstrated a true positive rate of 51.6 % in predicting PU development (Δ ≥ 0.6), significantly higher than the 29.7 % prediction rate of MCJ Scale (p < 0.001(. Furthermore, 28.1 % of patients developed PUs that were not predicted by MCJ (false negatives), compared to only 6.2 % with SEM scanner. The sensitivity of SEM scanner was 89.2 %, compared to 48.6 % of MCJ. The area under the curve was 0.880 for the SEM scanner versus 0.739 for MCJ. SEM scanner identified PU risk earlier than MCJ in 188 readings (35.1 %), with an average of 3.07 ± 2.93 days.

CONCLUSIONS

The SEM scanner was effective in detecting PUs three days earlier than MCJ. The SEM canner also reported more true positives of PU and more sensitivity than MCJ scale.

IMPLICATIONS FOR CLINICAL PRACTICE

Investing in advanced technology by integrating a reliable, evidence-based tool such as the SEM scanner into routine ICU care protocols, along with staff training, is crucial to guide clinical decision-making, reduce the variability in skin assessment, which ultimately reduces the incidence and severity of Hospital-Acquired PUs, and enhance patient outcomes.

Impact of Hydrocolloid Dressing and Moisturizing Cream as Facial Skin Protectants Among Health Care Workers

INTRODUCTION

During the novel coronavirus disease 2019 pandemic, health care workers experienced facial problems from prolonged use of N95 masks, including skin irritation, pigmentation changes, and contact dermatitis. We assessed the use of hydrocolloid dressing versus dimethicone cream to prevent skin breakdown among military health care workers while wearing an N95.

MATERIALS AND METHODS

Participants were recruited using convenience and snowball sampling in this nonblinded, randomized, cross-over study with 2 active treatments, hydrocolloid dressing and dimethicone cream, across 3 time points. The skin was assessed using photographs and subepidermal moisture scanner (SEM). N95 seal integrity was assessed using qualitative fit test. Institutional review board approval was obtained from the Madigan Army Medical Center Institutional Review Board.

RESULTS

Among the 73 participants, wearing an N95 alone versus with dimethicone cream or hydrocolloid dressing caused more adverse skin reactions. There were no significant differences in qualitative fit test failure rate between groups. Participants experienced minimal to no dizziness, loss of energy/tiredness/fatigue, claustrophobia, shortness of breath, difficulty breathing, and dry or itchy eyes. For all interventions, wearing an N95 did not interfere with participants' concentration, verbal communication, hearing, vision, and, importantly, delivery of care.

CONCLUSIONS

Using a skin protectant with an N95 may prevent adverse skin reactions while preserving health care workers' ability to safely and competently care for patients in routine and pandemic conditions.

The correlation between sub-epidermal moisture assessment and other early indicators of pressure ulcer development: A prospective cohort observational study. Part 2. The correlation between sub-epidermal moisture assessment, temperature, epidermal hydration and pain

There is growing interest in the roles of temperature, epidermal hydration (EH) and pain in pressure ulcer (PU) development. Investigating correlations between these measures and sub-epidermal moisture (SEM) will address this knowledge deficit. A prospective observational study enrolled 60 surgical patients from February to November 2021. SEM, temperature, EH and pain were assessed using a SEM scanner, thermography imaging, skin hydration device and numeric pain intensity scale, respectively. Measurements were taken at the sacrum, both heels and a control site, before and after surgery for 3 days. Data were analysed using Pearson or Spearman's correlation. Of the participants, 50% were male with a mean age of 58 years (±13.46). Low positive/negative correlations between SEM and temperature were found at the sacrum. However, after removing outliers, these results were not statistically significant. Other sites and follow-up days showed negligible correlations. No evidence of a correlation, to low correlations between SEM and EH were observed, but unreliable due to little variation in EH at the heels. Pain showed negligible correlations with SEM. This study did not find consistent evidence of a correlation between SEM, temperature, EH and pain, highlighting the unreliability of temperature and EH for early PU detection. Post-operative pain may also confound accurate pain assessments.

The complex interplay between mechanical forces, tissue response and individual susceptibility to pressure ulcers

OBJECTIVE

The most recent edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries was released in 2019. Shortly after, in 2020, the first edition of the SECURE Prevention expert panel report, focusing on device-related pressure ulcers/injuries, was published as a special issue in the Journal of Wound Care. A second edition followed in 2022. This article presents a comprehensive summary of the current understanding of the causes of pressure ulcers/injuries (PU/Is) as detailed in these globally recognised consensus documents.

METHOD

The literature reviewed in this summary specifically addresses the impact of prolonged soft tissue deformations on the viability of cells and tissues in the context of PU/Is related to bodyweight or medical devices.

RESULTS

Prolonged soft tissue deformations initially result in cell death and tissue damage on a microscopic scale, potentially leading to development of clinical PU/Is over time. That is, localised high tissue deformations or mechanical stress concentrations can cause microscopic damage within minutes, but it may take several hours of continued mechanical loading for this initial cell and tissue damage to become visible and clinically noticeable. Superficial tissue damage primarily stems from excessive shear loading on fragile or vulnerable skin. In contrast, deeper PU/Is, known as deep tissue injuries, typically arise from stress concentrations in soft tissues at body regions over sharp or curved bony prominences, or under stiff medical devices in prolonged contact with the skin.

CONCLUSION

This review promotes deeper understanding of the pathophysiology of PU/Is, indicating that their primary prevention should focus on alleviating the exposure of cells and tissues to stress concentrations. This goal can be achieved either by reducing the intensity of stress concentrations in soft tissues, or by decreasing the exposure time of soft tissues to such stress concentrations.

Biomarkers of local inflammation at the skin's surface may predict both pressure and diabetic foot ulcers

This commentary considers the similarities which exist between pressure ulcers (PUs) and diabetic foot ulcers (DFUs). It aims to describe what is known to be shared-both in theory and practice-by these wound types. It goes on to detail the literature surrounding the role of inflammation in both wound types. PUs occur following prolonged exposure to pressure or pressure in conjunction with shear, either due to impaired mobility or medical devices. As a result, inflammation occurs, causing cell damage. While DFUs are not associated with immobility, they are associated with altered mobility occurring as a result of complications of diabetes. The incidence and prevalence of both types of lesions are increased in the presence of multimorbidity. The prediction of either type of ulceration is challenging. Current risk assessment practices are reported to be ineffective at predicting when ulceration will occur. While systemic inflammation is easily measured, the presence of local or subclinical inflammation is harder to discern. In patients at risk of either DFUs or PUs, clinical signs and symptoms of inflammation may be masked, and systemic biomarkers of inflammation may not be elevated sufficiently to predict imminent damage until ulceration appears. The current literature suggests that the use of local biomarkers of inflammation at the skin's surface, namely oedema and temperature, may identify early tissue damage.

The correlation between sub-epidermal moisture measurement and other early indicators of pressure ulcer development-A prospective cohort observational study. Part 1. The correlation between sub-epidermal moisture measurement and ultrasound

The correlation between sub-epidermal moisture (SEM) and other early indicators of pressure ulcer (PU) development is yet to be determined. This three-part series aims to bridge this knowledge gap, through investigating SEM and its correlation with evidence-based technologies and assessments. This article focuses on the correlation between SEM and ultrasound. A prospective cohort observational study was undertaken between February and November 2021. Patients undergoing three surgery types were consecutively enrolled to the study following informed consent. Assessments were performed prior to and following surgery for 3 days at the sacrum, both heels and a control site, using a SEM scanner and high-frequency ultrasound scanner (5-15 MHz). Spearman's rank (rs ) explored the correlation between SEM and ultrasound. A total of 60 participants were included; 50% were male with a mean age of 58 years (±13.46). A statistically significant low to moderately positive correlation was observed between SEM and ultrasound across all anatomical sites (rs range = 0.39-0.54, p < 0.05). The only exception was a correlation between SEM and ultrasound on day 0 at the right heel (rs  = 0.23, p = 0.09). These results indicate that SEM and ultrasound agreed in the presence of injury; however, SEM was able to identify abnormalities before ultrasound.

Inter-device agreement of sacral subepidermal oedema measurement in healthy adults during prolonged 60° head of bed elevation

AIM

To investigate the level of agreement between the SEM 200 and Provisio® subepidermal moisture sacral delta measurements, which may indicate increased pressure injury risk, in healthy adults during 120 min of prolonged 60° head of bed elevation. This position, which requires the elevation of the patient's upper body at a 60° angle above the horizontal plane for an extended period, is used by clinicians to prevent or manage a patient's medical or surgical conditions.

DESIGN

This prospective exploratory study recruited 20 healthy adults during October 2021 and collected sacral subepidermal moisture delta measurements using the SEM 200 and Provisio® devices.

METHODS

Delta measurements were taken at 20-min intervals over 120 min resulting in seven data collection timepoints. Descriptive statistics and a Bland Altman plot analysis were conducted.

RESULTS

A total of 280 sacral subepidermal moisture delta measurements were gathered or 140 per device. There were good levels of agreement between the two devices at baseline (T0) [mean 0.025; SD 0.137] and following 60- (T3) [mean 0.025; SD 0.111], 80- (T4) [mean -0.01; SD 0.177] and 100 min (T5) [mean 0.01; SD 0.129] of prolonged 60° head of bed elevation. Head of bed elevations can increase a patient's risk of sacral pressure injuries. In some countries, nurses have access to the SEM 200 and/or the Provisio® device, so our findings may increase nurses' confidence in the interchangeability of the device measurements, although further research is needed to confirm this. The SEM 200 and Provisio® subepidermal moisture scanners show promise in gathering similar objective pressure injury risk data which could prompt clinicians to implement prevention strategies.

IMPACT

Current pressure injury risk assessment is largely subjective in nature. This quantitative study on healthy human sacral tissue found a good level of agreement in the SEM 200 and Provisio® subepidermal moisture scanners, which may increase nurses' confidence in the interchangeability of the devices in clinical practice.

Testing the effectiveness of a polymeric membrane dressing in modulating the inflammation of intact, non-injured, mechanically irritated skin

We investigated the inflammatory (IL-1 alpha) and thermal (infrared thermography) reactions of healthy sacral skin to sustained, irritating mechanical loading. We further acquired digital photographs of the irritated skin (at the visible light domain) to assess whether infrared imaging is advantageous. For clinical context, the skin status was monitored under a polymeric membrane dressing known to modulate the inflammatory skin response. The IL-1 alpha and infrared thermography measurements were consistent in representing the skin status after 40 min of continuous irritation. Infrared thermography overpowered conventional digital photography as a contactless optical method for image processing inputs, by revealing skin irritation trends that were undetectable through digital photography in the visual light, not even with the aid of advanced image processing. The polymeric membrane dressings were shown to offer prophylactic benefits over simple polyurethane foam in the aspects of inflammation reduction and microclimate management. We also concluded that infrared thermography is a feasible method for monitoring the skin health status and the risk for pressure ulcers, as it avoids the complexity of biological marker studies and empowers visual skin assessments or digital photography of skin, both of which were shown to be insufficient for detecting the inflammatory skin status.

The effect of prolonged 60° head of bed elevation on sacral subepidermal oedema in healthy adults: A quantitative prospective exploratory study

Head of bed elevation is used to manage some medical and surgical conditions however this may increase a patient's risk of sacral pressure injuries. Novel point-of-care technologies that measure subepidermal moisture can identify changes in localised subepidermal oedema and potential pressure injury risk. This prospective exploratory study investigated variations in sacral subepidermal oedema in healthy adults during 120-min of 60° head of bed elevation. Sacral subepidermal oedema was measured at 20-min intervals using the Provisio® subepidermal moisture scanner. Descriptive analysis, one-way repeated measures analysis of variance and an independent t-test were conducted. Slightly more male volunteers (n = 11; 55%) were recruited and the sample mean age was 39.3 years (SD 14.7) with an average body mass index of 25.8 (SD 4.3). Little variation in the mean sacral subepidermal moisture of healthy adults was observed. There was a statistically significant difference in the mean sacral subepidermal moisture measurements between males and females (Mean difference 0.18; 95% confidence intervals: 0.02 to 0.35; P = .03). Healthy adults can tolerate prolonged 60° head of bed elevation without developing increased subepidermal sacral oedema. This warrants further investigation in other populations, in various positions and over different time periods.

Variations in sacral sub-epidermal moisture measurements in hospitalized medical and surgical patients: A longitudinal observational sub-study

BACKGROUND

Pressure injury risk assessment tools have several well-known limitations. As a result, new methods of assessing risk are emerging, including the use of sub-epidermal moisture measurement to detect localized edema.

AIMS

To assess the daily variation in sacral sub-epidermal moisture measurement over five days and establish if age and prophylactic sacral dressing use influenced these measurements.

METHODS

As part of a larger randomized controlled trial of the use of prophylactic sacral dressings, a longitudinal observational substudy was undertaken in hospitalized medical and surgical adult patients at risk of pressure injury. The substudy was conducted in consecutively recruited patients from 20 May 2021 to 9 November 2022. Using the SEM 200 (Bruin Biometrics LLC), daily sacral sub-epidermal measurements for up to five days were completed. Two measurements were generated, the most recent sub-epidermal moisture measurement and, after at least three measurements, a delta value, the difference between the highest and lowest values. The delta measurement was the outcome, with a delta of ≥0.60 considered abnormal, increasing the risk of pressure injury development. A mixed analysis of covariance was undertaken to determine if there was any change in delta measurements over the five days and to determine if age and sacral prophylactic dressing use influenced sub-epidermal moisture delta measurement.

RESULTS

A total of 392 participants were included in this study; 160 (40.8%) patients had completed five consecutive days of sacral sub-epidermal moisture delta measurements. In total, 1324 delta measurements were undertaken across the five study days. In total, 325 of 392 patients (82.9%) had experienced one or more abnormal delta. Furthermore, 191 (48.7%) and 96 (24.5%) of patients experienced abnormal deltas for two or more and three or more consecutive days. There was no statistically significant variation in sacral sub-epidermal moisture delta measurements over time; increasing age and prophylactic dressing use did not influence sub-epidermal moisture deltas over the five days.

CONCLUSION

If only one abnormal delta was used as a trigger, about 83% of patients would have received additional pressure injury prevention strategies. But, if a more nuanced approach to responding to abnormal deltas is taken, between 25 and 50% of patients may receive additional pressure injury prevention, representing a more time and resource efficient approach.

TWEETABLE ABSTRACT

Sub-epidermal moisture delta measurements did not vary over 5 days; increasing age and prophylactic dressing use did not influence these measurements.

Use of point-of-care subepidermal moisture devices to detect localised oedema and evaluate pressure injury risk: A scoping review

AIMS AND OBJECTIVES

To map current literature on bedside clinicians' use of point-of-care subepidermal moisture devices to identify increased pressure injury risk.

BACKGROUND

Pressure injuries are a substantial healthcare burden. Localised oedema occurs before visible or palpable changes, and therefore is a biomarker of increased pressure injury risk. Novel bedside technologies that detect localised oedema may aid early pressure injury preventative practices.

DESIGN

A scoping review.

METHODS

Arksey and O'Malley's six-step framework and the PRISMA-ScR guidelines guided this scoping review. CINAHL Complete, Embase, SCOPUS, Cochrane (wounds) and PubMed databases were searched for primary research and quality improvement projects published in English between 2008-2022. Included studies focused on clinicians' bedside use of subepidermal moisture devices to quantify localised oedema and pressure injury risk. The PAGER framework supported narrative synthesis of the extracted data.

RESULTS

Nine studies were selected from 1676 sources. Two point-of-care subepidermal moisture devices were identified in clinical use, largely by nurses. Inconsistent use and interpretations revealed significant knowledge gaps in clinical practice. Additionally, no included studies engaged patients or the public in their design.

CONCLUSIONS

Nurses recognise the value of objective measures in determining the risk of pressure injury and are the primary end-users of point-of-care subepidermal moisture devices. However, standardising procedural instructions and interpretive criteria to guide preventative measures requires further research.

RELEVANCE TO CLINICAL PRACTICE

International pressure injury clinical practice guidelines advocate for subepidermal moisture devices as an adjunct to routine clinical skin assessment, although little is known about bedside use. This scoping review reveals low adoption of such devices and the need to develop standardised procedures in their use and interpretation.

REGISTRATION

Open Science DOI https://doi.org/10.17605/OSF.IO/AB6Y5-7th of March 2022.

Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BACKGROUND

Subepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.

AIM

The primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.

METHODS

Healthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.

RESULTS

A total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.

CONCLUSION

In a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.

Prediction of internal changes in the sacral region on immobility using bio-mechanical and bio-thermal modelling

Pressure injury usually develop in the bony prominence of immobile bedridden subjects. Predicting pressure injuries based on the subjects’ physiological information will reduce the burden of the caretakers in adjusting the frequency of repositioning such subjects. Visual assessment, diagnostic, and prognostic approaches only provide pressure injury information after onset. Therefore, the objective of this unique modeling technique is to predict the internal alterations that take place in human tissues before the onset of pressure injuries. In this approach the bio-mechanical and bio-thermal properties was integrated to predict the internal changes of skin, fat, and muscle layers when subjects were self-loaded continuously for one hour in the sacrum region. A change in temperature of all the layers, as well as the distribution of Von-Mises stress in these layers, was observed. The inflammation caused by the changes in the temperature and the stress was measured from the simulation model. Ultrasound measurements was also taken for the same subjects in the supine position in the sacral region, before and after one hour by applying a self-load. An identical change in the thickness of the above-mentioned layers due to thermal expansion was noticed. Hence this computational model is hypothesized to give identical thermal expansion in comparison with the ultrasound measurements. There was an agreement between the thermal expansion using the simulation technique and the ultrasound technique which was assessed through Bland-Altman analysis, with a 96% confidence interval.

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial

AIM

Sub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS.

MATERIALS AND METHODS

This pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes.

RESULTS

Of 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing.

CONCLUSIONS

Most feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.

Skin hydration measurement and the prediction of the early development of pressure ulcers among at risk adults: A systematic review

This systematic review aimed to examine skin hydration and determine if this biophysical parameter can predict pressure ulcer development in at risk adults. A literature search was conducted in March 2022, using PubMed, CINAHL, SCOPUS, Cochrane, and EMBASE databases. A total of 1727 records were returned, with 9 studies satisfying the inclusion criteria. Data were extracted using a pre-designed extraction tool and a narrative synthesis of the data was undertaken. The methodological quality of the included articles was assessed using the evidence-based librarianship checklist. Included studies were published between 1997 and 2021, with most using a prospective cohort design (88.9%, n = 8). The mean sample size was 74 participants (SD = 38.6; median 71). All studies measured skin hydration objectively, with 55.6% (n = 5) using the Corneometer® CM825 and 33.3% (n = 3) of studies reported a statistically significant association between skin hydration and pressure ulcer development. The mean evidence-based librarianship percentage was 66.6% (SD: 20.7%), however, only 33.3% (n = 3) of studies scored ≥75%, indicating validity. The quality of included studies, methodology variation, and reported results has reduced the homogeneity of outcomes. This review highlights the requirement for future research evidence to ascertain the role of skin hydration in pressure ulcer development.

Biomarkers for the early detection of pressure ulcers in the intensive care setting: A comparison between sub-epidermal moisture measurements and interleukin-1α

Pressure ulcer (PU) prevention in the intensive care unit (ICU) is an important clinical issue as critically unwell patients are at high risk of developing PUs. However, current methods of PU detection are limited, especially for early detection. This study aimed to establish the correlation between Interleukin-1α (IL-1α)/total protein (TP) and sub-epidermal moisture (SEM) measurements in the early identification of PUs in ICU patients. This study employed an observational research design using the STROBE guidelines. Following ethical approval, 53 participants were recruited and sebum was obtained using Sebutape from weight-bearing areas (sacrum, heels and a control site). SEM measurements were taken from the same anatomical sites. Both measures were taken at the same time and participants were followed up for 5 days, or until discharge or death. Correlations between SEM delta measurements, IL-1α, TP and PU incidence and other demographic information were explored using Spearman's correlation for data not normally distributed, and Pearson's R correlation coefficient for normally distributed data. Mean baseline SEM delta measurements indicate abnormal readings for all anatomical sites except the control site, consistent with previous studies. Mean baseline IL-1α/TP readings were higher for the sacrum versus both heels and, on average, readings were higher for the control site versus all other anatomical locations. This is conflicting, given that the control site was non-weight bearing. There were very weak or weak correlations between SEM delta measurements and IL-1α/TP readings. SEM measurements are quick and easy to obtain and results are instant, however Sebutape sampling takes significantly longer and is challenging to conduct among haemodynamically unstable patients. Obtaining SEM measurements is more practical and feasible than Sebutape sampling to assess for the presence of inflammation.

Measuring subepidermal moisture to detect early pressure ulcer development: a systematic review

OBJECTIVE

The aim was to assess evidence related to the measuring of subepidermal moisture (SEM) to detect early, nonvisible development of pressure ulcers (PUs).

METHOD

Using systematic review methodology, all quantitative animal and human research studies written in English were considered. In January 2021, PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases were searched. The primary outcome of interest was the validity of SEM measurement to detect early PU development. The secondary outcome was time to PU detection, sensitivity and specificity of SEM measurement, and the impact of SEM measurements on PU prevention. Data analysis was undertaken using RevMan and narrative synthesis.

RESULTS

A total of 17 articles met the inclusion criteria. In all studies, a consistent abnormal deviation in SEM measurements corresponded with evidence of visual PU development. Time to PU development, explored in four studies, showed earlier detection of PU development using SEM measurement. RevMan analysis identified the mean difference in time to PU development (SEM measurement versus visual skin assessment, VSA) was 4.61 days (95% confidence interval: 3.94-5.28; p=0.0001) in favour of SEM measurements. The sensitivity of SEM measurements was reported in four studies, and scores varied from 48.3% to 100.0%. Specificity was also reported in four studies and scores ranged from 24.4% to 83.0%. The impact of the detection of abnormal SEM measurements on PU prevention was explored by one study. Results showed a 93% decrease in PU rates when staff acted on the results of the SEM readings.

CONCLUSION

The findings of this review identified that SEM measurement detects PU development earlier than VSA. Furthermore, when staff responded to abnormal SEM measurements, prevention strategies were enhanced, with a subsequent reduction in visible PU development. SEM measurement may therefore be a useful addition to PU prevention strategies.

DECLARATION OF INTEREST

The School of Nursing & Midwifery, RCSI has a research agreement with Bruin Biometrics. Funding for the study was through an Irish Research Council PhD Enterprise Partnership Scheme with Bruin Biometrics. The authors have no other conflicts of interest.

Oedema as a predictor of the incidence of new pressure injuries in adults in any care setting: A systematic review and meta-analysis

BACKGROUND

Oedema measurement, also termed sub-epidermal moisture measurement is recommended as an adjunct pressure injury prevention intervention in international guidelines because it indicates early tissue damage.

OBJECTIVE

To determine the prognostic value of oedema measurement in predicting future pressure injury in adults in any care setting.

DESIGN

Systematic review and meta-analysis.

SETTING

Participants were recruited from nursing homes or aged care facilities, hospitals, or post-acute facilities.

PARTICIPANTS

Adults.

METHODS

A modified 2-week systematic review was undertaken. Study designs included cohort (prospective and retrospective), case-control, case series if relevant comparisons were reported, randomised controlled trials if the association between oedema measurement and pressure injury was reported, and registry data. Databases searched included: Medical Literature Analysis and Retrieval System Online, The Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica and the Cochrane Library from inception to 13 July 2021 with no language restrictions. Screening, data extraction using Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies - Prognostic Factors (CHARMS-PF) and quality assessment using Quality in Prognostic Factor Studies (QUIPS) were undertaken independently by ≥2 authors and adjudicated by another if required. Meta-analyses and meta-regression were undertaken. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Six studies (n = 483 total) were included. Two studies were set in nursing homes and four in either hospitals or post-acute facilities. Fives studies were prospective cohorts, and one was a randomised control trial. Two studies were assessed as low risk and four studies as moderate risk of bias. The pooled risk ratio in four studies (n = 388) for the relationship between oedema and pressure injury cumulative incidence was 18.87 (95% CI 2.13-38.29) and for time to pressure injury was 4.08 days (95% CI 1.64-6.52). Using GRADE, the certainty of the body of evidence was low for all outcomes. Meta-regression indicated that age, gender, and sample size were poor predictors for the association between oedema and pressure injury.

CONCLUSIONS

Measuring oedema as a predictor for pressure injury development is showing promise but a stronger body of evidence that takes into consideration other prognostic factors is needed to better understand its benefit.

REGISTRATION

PROSPERO CRD42021267834.

TWEETABLE ABSTRACT

Measuring oedema is a promising strategy to prevent pressure injuries but the certainty of evidence for this claim is low.

A Study on Pressure Ulcer: Influencing Factors and Diagnostic Techniques

Pressure ulcer (PU) is one of the most common occurrences in bedridden subjects. Despite the standard of care, there is a huge challenge in monitoring immobile subjects in all the bodily pressure points. This increases the chance of onset of PU which in turn increases the expenditure for treating and managing the PU. Hence, we made a study on the biological and physiological factors that are responsible for the formation of PU and also on various techniques used for diagnosis. Thus, we have summarised the efficacy of various advanced diagnostic procedures with their limitations. Though there are advanced imaging techniques, risk assessment tools based on the visual inspection are widely followed in hospitals. Based on our observation, we here have identified three major areas; one being the development of mathematical modeling, the second is towards the development of non-invasive devices and finally to automate cot facility. We have also provided possible suggestions as to solutions that could be useful to researchers and for society. Thus, this review covers the present difficulty faced by bedridden subjects and respective care-takers along with the knowledge gap and a few suggestions as to future scope.

The performance of gelling fibre wound dressings under clinically relevant robotic laboratory tests

The effectiveness of wound dressing performance in exudate management is commonly gauged in simple, non‐realistic laboratory setups, typically, where dressing specimens are submersed in vessels containing aqueous solutions, rather than by means of clinically relevant test configurations. Specifically, two key fluid–structure interaction concepts: sorptivity—the ability of wound dressings to transfer exudate, including viscous fluids, away from the wound bed by capillary action and durability—the capacity of dressings to maintain their structural integrity over time and particularly, at removal events, have not been properly addressed in existing test protocols. The present article reviews our recent published research concerning the development of clinically relevant testing methods for wound dressings, focussing on the clinical relevance of the tests as well as on the standardisation and automation of laboratory measurements of dressing performance. A second objective of this work was to compile the experimental results characterising the performance of gelling fibre dressings, which were acquired using advanced testing methods, to demonstrate differences across products that apparently belong to the same “gelling fibre” family but differ remarkably in materials, structure and composition and, thereby, in performance.

A machine learning algorithm for early detection of heel deep tissue injuries based on a daily history of sub-epidermal moisture measurements

Sub‐epidermal moisture is an established biophysical marker of pressure ulcer formation based on biocapacitance changes in affected soft tissues, which has been shown to facilitate early detection of these injuries. Artificial intelligence shows great promise in wound prevention and care, including in automated analyses of quantitative measures of tissue health such as sub‐epidermal moisture readings acquired over time for effective, patient‐specific, and anatomical‐site‐specific pressure ulcer prophylaxis. Here, we developed a novel machine learning algorithm for early detection of heel deep tissue injuries, which was trained using a database comprising six consecutive daily sub‐epidermal moisture measurements recorded from 173 patients in acute and post‐acute care settings. This algorithm was able to achieve strong predictive power in forecasting heel deep tissue injury events the next day, with sensitivity and specificity of 77% and 80%, respectively, revealing the clinical potential of artificial intelligence‐powered technology for hospital‐acquired pressure ulcer prevention. The current work forms the scientific basis for clinical implementation of machine learning algorithms that provide effective, early, and anatomy‐specific preventive interventions to minimise the occurrence of hospital‐acquired pressure ulcers based on routine tissue health status measurements.

Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up‐to‐date evidence‐based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.

The identification of biophysical parameters which reflect skin status following mechanical and chemical insults

BACKGROUND

Skin is constantly exposed to mechanical and chemical insults, in the form of prolonged loading, overhydration or exposure to irritants. An array of non-invasive biophysical tools has been adopted to monitor the changes in skin response. The present study aims to identify a set of robust parameters sensitive to mechanical and chemical challenges to skin integrity.

MATERIALS AND METHODS

Eleven healthy participants were recruited to evaluate the skin response following mechanical loading, tape stripping, overhydration and chemical irritation. Forearm skin responses were recorded at baseline and at three time points following the insult. Measurements included transepidermal water loss, sub-epidermal moisture, erythema and laser Doppler imaging. Thresholds were informed by basal values, and the sensitivity of parameters to detect skin changes was evaluated.

RESULTS

High degree of variability in skin response was observed with selected biophysical parameters, such as sub-epidermal moisture, laser Doppler imaging and erythema, even in the absence of an applied insult. Temporal skin response revealed distinct response profiles during each evoked insult. Indeed, the sensitivity of the biophysical parameters was influenced by the threshold values and time point of measurement. Some statistically significant correlations were determined between the biophysical parameters.

CONCLUSION

The study revealed that thresholds derived from single biophysical parameters were limited in detecting skin changes following insults. A complementary evaluation using combined parameters has the potential to provide a more sensitive assessment. Further research is required to identify robust biophysical parameters, to aid the early detection of skin damage in clinical settings.

The sorptivity and durability of gelling fibre dressings tested in a simulated sacral pressure ulcer system

Wound‐dressing performances are affected by exudate viscosity, resistance to flow because of gravity, and bodyweight loads, the level of which is related to the body position. Here, we focussed on two dressing properties: (a) Sorptivity—the ability of dressings to transfer exudate away from the wound bed by capillary action—and (b) Durability—the capacity of dressings to maintain their integrity over time and during their removal. Both properties are critically important for avoiding further tissue damage but require the development of new laboratory tests for their measurement. A computer‐controlled phantom of an exuding sacral pressure ulcer has therefore been developed and used to compare the performances of Exufiber (Mölnlycke Health Care) vs an alternative market‐leading dressing. Sorptivity was determined using weight tests, and durability was measured through tensile tests of the used dressings. For a supine configuration, the Exufiber dressing demonstrated ~three times higher sorptivity and better durability, withstanding ~five times greater strain energy than the other product before failure occurred. This work paves the way for quantitative, standardised testing of dressings in all aspects of exudate management. The reported tests are further suitable for testing dressing combinations or how dressings interact with negative pressure wound therapy.

The cost-effectiveness of sub-epidermal moisture scanning to assess pressure injury risk in U.S. health systems

Objective

Hospital-acquired pressure injuries harm over 2.5 million patients at a U.S. cost of $26.8 billion. Sub-epidermal moisture scanning technology supports clinicians to anatomically identify locations at-risk of developing hospital-acquired pressure injuries. Our objective was to evaluate the cost-effectiveness of adopting sub-epidermal moisture scanners in comparison to existing hospital-acquired pressure injury prevention guidelines structured around subjective risk assessments.

Methods

A Markov cohort model was developed to analyze the cost-effectiveness of sub-epidermal moisture scanners in comparison to existing prevention guidelines, based on current clinical trial data from the U.S. health care sector perspective in the acute, acute rehabilitation and skilled nursing facility settings. A hypothetical cohort was simulated over a time horizon of one year. An incremental cost-effectiveness ratio was measured using U.S. dollars per quality-adjusted life year at a willingness-to-pay threshold of $100,000/quality-adjusted life year, and uncertainty was tested using probabilistic sensitivity analysis.

Results

Integration of sub-epidermal moisture scanners yielded cost-savings of $4054 and 0.35 quality-adjusted life years gained per acute care admission, suggesting that sub-epidermal moisture scanners are a dominant strategy compared to standard care and producing a net monetary benefit of $39,335. For every 1000 admissions in high-risk acute care, sub-epidermal moisture scanners could avert around seven hospital-acquired pressure injury-related deaths and decrease hospital-acquired pressure injury-related re-hospitalization by approximately 206 bed-days.

Conclusions

Acute care, acute rehabilitation and skilled nursing settings that adopt sub-epidermal moisture technology could achieve a return on investment in less than one year. Providers may want to consider these types of technology that aid clinical judgment with objective measures of risk in quality improvement bundles.