Implementing a Pressure Injury Care Bundle in Chinese Intensive Care Units

Identification of Nursing-Sensitive Indicators on Pressure Injuries/Ulcers: A Systematic Review

This systematic review aims to develop a conceptual framework to identify nursing-sensitive indicators for preventing and managing pressure ulcers. The first step involves defining evidence-based indicators critical to effective prevention and management. The second step examines the relationships influencing the management of these indicators, using insights derived from scientific research findings. This review is guided by a conceptual framework rooted in Structural State Theory and uses a methodological approach. A total of 956 articles were identified through a search of original references from Medline/PubMed, Scopus, Cochrane Library, and CINAHL, covering the period from 2012 to 2023. A systematic review of 29 studies identified 241 relationships between dependent and independent variables. A theoretical conceptual framework highlighted nursing-sensitive indicators (independent variables) related to patients, nurses, pressure injury/ulcer management, organizational structure, and their association with pressure injury/ulcer outcomes (dependent variables). The analysis showed that patient-focused studies had the highest frequency of relationships. This review highlights the complexity of managing pressure injuries/ulcers and the essential role of nursing care practices and interventions in shaping outcomes. The findings highlight the need for specialized wound care nurses and further research on nursing interventions, urging hospitals to invest in structural changes and nurse education.

Application of pressure injury preventive measures and bundles in home and community environments: a scoping review protocol

INTRODUCTION

Several studies have addressed the use of pressure injury preventive measures and bundles for hospitalised patients. However, there is a gap in research regarding the use of pressure injury preventive measures and bundles in the home environment. This scoping review aims to identify, explore and map the international literature on pressure injury preventive measures and bundles in the home and community environments.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will be used to guide the reporting of this scoping review. The Joanna Briggs Institute guide will inform the methods. A modified version of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols will be used to guide the reporting of this scoping review protocol. An initial search was carried out in July 2024. The search will be conducted in electronic databases such as LILACS, SciELO, Scopus, PubMed, Embase, CINAHL, Cochrane Library and Web of Science. The search will be restricted to studies in English, Portuguese and Spanish, with no time restriction. Additional literature will be retrieved by reviewing the reference lists of the selected studies based on their titles. Two independent reviewers will carry out the data extraction process. Essential details, including the author, references and findings pertinent to the review questions, will be collected. The findings will be displayed through graphs, tables and figures, supplemented by a narrative summary.

ETHICS AND DISSEMINATION

As this review will be conducted using secondary data, ethical approval is not required. Results will be shared with the international scientific community through conference presentations and publication in a high-impact journal.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework registry (osf.io/m5gvn) on 8 August 2024.

Implementation of a risk-stratified intervention bundle to prevent pressure injury in intensive care: A before-after study

BACKGROUND

Hospital-acquired pressure injury is an enduring problem in intensive care. Several intensive care-specific pressure injury risk assessment tools have been developed, but to date, only the COMHON Index has been aligned with risk-stratified preventative interventions.

OBJECTIVES

The aim of this study was to evaluate the effectiveness of a risk-stratified intervention bundle to reduce pressure injury in intensive care and to assess compliance with bundled interventions.

METHODS

A controlled before-after study was undertaken. All patients admitted to a single intensive care unit were included. Standard care was provided in the before phase, and the risk-stratified intervention bundle was implemented in the after phase. The primary outcome measure was pressure injury incidence.

RESULTS

The sample comprised 761 intensive care admissions. In the after phase, pressure injury incidence was reduced (2.1% vs 3.9%; 46% relative risk reduction), injury severity was lower, and there were fewer pressure injuries on the sacrum, buttocks, and heels. Logistic regression modelling identified three significant factors associated with pressure injury development: intensive care length of stay (odds ratio: 1.2); COMHON Index admission score (odds ratio: 1.2), and the before phase (odds ratio: 4.2). In the after phase, individual intervention compliance was variable (range: 40%-100%), but the all-or-nothing compliance was poor (33%).

CONCLUSIONS

Implementation of bundled preventive measures associated with COMHON Index risk level reduced pressure injury incidence. Likewise, injury severity decreased, and the location of pressure injuries changed following the intervention. The results from this study support the use of risk-stratified interventions to prevent pressure injury in intensive care. However, further research is needed to examine the effectiveness of the COMHON Index bundle before it can be recommended for widespread clinical practice.

Impact of Care Bundles Prevention of Hospital-Acquired Pressure Injuries: A Systematic Review and Meta-Analysis

AIM

To describe and synthesise current literature on care bundles in preventing hospital-acquired pressure injuries and to present a meta-analysis of experimental studies evaluating the effects of care bundles.

DESIGN

A systematic review and meta-analysis.

METHODS

Pubmed, Cochrane Library, Scopus, Web of Science, CINAHL, Google Scholar and Medline (OVID), and relevant articles were identified from the inception of each database until June 5, 2024. This systematic review has been registered in PROSPERO (CRD42024554497). This study examined a multicomponent intervention care bundles consisting of three or more components that was implemented and compared with standard care. Outcomes were assessed using rates of hospital-acquired pressure injuries, length of hospital stay (days) and the number of pressure injuries. Study types included randomised controlled trials, nonrandomised studies, quasi-experimental studies, and cohort studies. After completion of the search, titles, abstracts and full texts were independently assessed by two researchers in consecutive rounds according to PICOS criteria; data were extracted and study quality was independently assessed by at least two researchers. A meta-analysis using random effects was conducted, where estimates were combined as odds ratios or risk differences, along with proportions and 95% confidence intervals were calculated.

RESULTS

A total of nine published studies, including 29.572 patients (Control group: 56.8%; Intervention group: 43.2%) were included in this review. The meta-analysis results showed a significant effect of care bundle intervention on hospital-acquired pressure injuries rates, length of hospital stay and number of pressure injuries. According to the results of the study, care bundle application reduces the rate of hospital-acquired pressure injuries, shortens the duration of hospitalisation, and reduces the number and severity of pressure injuries.

NO PATIENT OR PUBLIC CONTRIBUTION

Although patients and the public were not directly involved in the study, the research addresses key concerns about preventing hospital-acquired pressure injuries. By focusing on care bundles to improve patient safety and reduce pressure injury rates, this study aims to enhance the quality of care, shorten hospital stays and improve patient outcomes, ultimately benefiting both patients and the healthcare system.

TRIAL REGISTRATION

CRD42024554497.

Integration of the aSSKINg framework into the electronic patient record: a quality improvement project

Assessment of pressure ulcer (PU) risk is important in clinical practice and the need to document it in the patient's record is paramount. Despite national and international guidelines highlighting the need to document PU risk, nursing documentation remains variable. The first article in this series discussed the evidence base underpinning the development of clinical guidelines for PUs, alongside the creation of bundle approach for PU prevention. The second article presented the results of a clinical audit exploring compliance against a PU prevention bundle (aSSKINg framework) in an adult community nursing setting in the South East of England. This final article in the series presents the results of a quality improvement project that involved a clinical audit following the implementation of the aSSKINg framework into the electronic patient record (EPR). The aim was to improve nursing documentation for patients with PU risk. The clinical audit was conducted in two parts, with a pilot phase running between 6 February 2023 and 15 April 2023. After the template implementation into the EPR, a follow-up audit was undertaken between 1 November 2023 and 31 January 2024. Overall compliance against the aSSKINg framework improved, especially the completion of the PURPOSE-T on the first visit, full skin assessment and repositioning advice. Following the pilot phase, the aSSKINg template was rolled out in a phased approach to the adult community nursing, enhanced care home matrons and urgent community response teams.

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

AIM AND OBJECTIVES

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

BACKGROUND

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

DESIGN

Integrative review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Implementation of the REPRISE care bundle model for the prevention of pressure ulcers in an intensive care unit: An experimental study

The aim of this study was to evaluate the effectiveness of the REPRISE care bundle (CB) model for pressure ulcer (PU) prevention in intensive care patients and to determine the impact of the training provided to nurses on their knowledge base and attitudes. This study has an experimental design. The study was conducted in the anaesthesia and resuscitation intensive care unit on a total of 72 patients. The prevalence of PU was compared between the control group and the REPRISE-CB group. For the nurses, 50 nurses working in the ICU were included in the study. The nurses' knowledge and attitudes towards PU were compared before and after the training. The data were analysed using a statistical program. The incidence of IW was significantly lower in the intervention group (13.9%) compared to the control group (38.9%) (p < 0.05). The study showed that oedema, low albumin levels, low mean blood pressure and low Braden Scale scores were significant risk factors for the development of PU. In addition, the training provided to nurses was found to significantly improve their knowledge and attitudes (p < 0.05). It was concluded that REPRISE-CB was effective in the prevention of PU and that nurses' knowledge increased with training.

Pressure ulcers: a clinical audit to determine compliance against the aSSKINg framework in an adult community nursing setting

Assessment of pressure ulcer (PU) risk remains a challenge in clinical practice. The first part of this article (Martin and Holloway, 2024) discussed the evidence base underpinning the development of clinical guidelines for PUs alongside the creation of the bundle approach regarding PU prevention. This article, part two, presents the results of a clinical audit that explores compliance against a PU prevention bundle (the aSSKINg framework) in an adult community nursing setting in the south-east of England. The clinical audit was conducted between July-December 2021 and included records of 150 patients. Overall, compliance against the aSSKINg framework was poor, with only two criterion being met: equipment provision for chair and referral to the tissue viability team. Short-term recommendations are that mandatory PU training for staff in the management of PUs should be implemented, and the tissue viability nurse network should be increased. The long-term recommendation was the introduction of the aSSKINg framework as a template into the electronic patient record.

Pressure ulcers: aSSKINg framework study

Pressure ulcers (PUs) represent a burden to the health economy and patients alike. Despite national and international guidelines regarding the management of risk, the incidence and prevalence across England remains high. Detecting early the risk of PUs is paramount, and requires using a valid risk assessment tool alongside clinical judgement and management of associated risk factors. There is a need to implement prevention strategies. Introducing care bundles for pressure ulcers, for example SKIN, SSKIN and most recently aSSKINg, is designed to guide clinicians and reduce variations in care. This article presents a review of the evidence on compliance with guidelines, frameworks, pathways or care bundles within primary and secondary care settings. This article focuses on the literature review that was conducted to inform a subsequent clinical audit of compliance with the aSSKINg framework in a Community NHS Foundation Trust in the South East of England.

The effect of knowledge levels of intensive care nurses about pressure injuries on their attitude toward preventing pressure injuries

AIM

The aim of this study was to determine the current knowledge levels of intensive care nurses about pressure injuries and their attitudes toward preventing pressure injuries, and to reveal the relationship between these variables.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted with 152 nurses, working in the Adult Intensive Care Units of a Training and Research Hospital. Data were collected between 10.08.2021 and 31.11.2021 with the Patient Information Form, Modified Pieper Pressure Ulcer Knowledge Test and Attitude toward Pressure Injury Prevention Scale. Frequency analysis, descriptive statistics, multiple logistic regression analysis and the structural equation modeling technique were used in the analysis of the study data.

RESULTS

The mean age of the nurses was 25.82 ± 3.42 years, 86.2% of them were female and 67.1% of them had a bachelor's degree. Total mean score of the Modified Pieper Pressure Ulcer Knowledge Test of the intensive care nurses was found to be 32.58 ± 6.58. The knowledge score of 113 out of 152 nurses was ≥60% or above. The total mean score of the Attitude toward Pressure Injury Prevention Scale was 42.00 ± 5.70 and a total of 76.97% (117 participants) of them were found to score 75% or above on the scale. The results of the regression analysis showed that educational degree, and status of having training about pressure injuries did not affect the total mean score of the Knowledge Test and the Attitude Scale. However, it revealed that the frequency of encountering a patient with pressure injuries in the unit where they work has affected the total mean score of the scales significantly (p < 0.05). As per the results of the structural equation model, the Modified Pieper Pressure Ulcer Knowledge Test scores of the nurses were found to have a statistically significant effect on the scores of the Attitude toward Pressure Injury Prevention Scale (p < 0.05).

CONCLUSION

This study revealed that intensive care unit nurses had a positive attitude toward Pressure Injury Prevention and their knowledge was sufficient and that as the Modified Pieper Pressure Ulcer Knowledge Test scores increase, their positive attitude toward Pressure Injury Prevention also increases.

Reduction in the Incidence Density of Pressure Injuries in Intensive Care Units after Advance Preventive Protocols

(1) Background: Patients who are critically ill or undergo major surgery are admitted to intensive care units (ICUs). Prolonged immobilization is the most likely cause of pressure injuries (PrIs) in the ICU. Previous studies of Western populations found that effective protocols could reduce the incidence of PrIs, and the efficacy of systemic targeted intervention protocols in preventing PrIs in the Chinese population needs to be surveyed. (2) Methods: We reviewed cases of PrIs in the ICUs of Taipei Veterans General Hospital from 2014 to 2019. The ICU nurses at the hospital began to implement targeted interventions in January 2017. The incidence density of PrIs was calculated by dividing the number of PrIs by person days of hospitalizations in the pre-bundle (2014-2016) and post-bundle (2017-2019) stages. Poisson regression was performed to compare the trend of incidence densities. (3) Results: The incidence density of PrIs was 9.37/1000 person days during the pre-bundle stage and 1.85/1000 person days during the post-bundle stage (p < 0.001). The relative risk (RR) was 0.197 (95% confidence interval: 0.149-0.26). The incidence densities of iatrogenic PrIs and non-iatrogenic PrIs decreased as the RRs decreased. (4) Conclusions: Targeted interventions could significantly reduce the incidence of PrIs. Healthcare providers must follow the bundle care protocol for PrI prevention to improve the quality of healthcare and promote patient health.

Care bundle for family interview for pediatric organ donation

PURPOSE

to develop a care bundle for best practices in conducting the family interview for organ and tissue donation with the families of children and adolescents.

DESIGN AND METHODS

methodological study, with a qualitative approach, developed in Brazil, in three stages: literature review, qualitative study with professionals and family members, and development of the care bundle.

RESULTS

Nine studies were selected and 17 health professionals and nine family members were interviewed. With this data, the care bundle was developed in three categories: communication of death, emotional support and information about organ and tissue donation. The recommendations were evaluated by five external professionals and all of them assessed the bundle as having the highest possible quality.

CONCLUSIONS

the care bundle was built following the stages of integrative literature review and interviews with professionals working in this scenario and family members who have already gone through a family interview for organ and tissue donation of children and adolescents.

PRACTICE IMPLICATIONS

the use of this material is seen as an important resource to support the professional during the conduction of the family interview in a scenario as sensitive and challenging as the care to family members facing death and the decision of organ and tissue donation of children and adolescents. Furthermore, the care bundle can increase the quality of family interviews and impact the reduction of family refusals.

DESCRIPTORS

Practice Guideline as Topic. Tissue and Organ Procurement. Patient Care Team. Nursing. Pediatrics. Communication.