Risk factors for pressure injuries among critical care patients: A systematic review

Clinical Burden of Inpatient Wound Care in Internal Medicine Units During the First Wave of COVID-19 Outbreak

OBJECTIVE

To explore the clinical burden and epidemiologic profile of hospitalized patients with wounds during the first wave of COVID-19.

METHODS

A retrospective and observational study was conducted to analyze the inpatient episodes of wound care in the University Hospital of Salamanca (Spain) during the initial COVID-19 crisis from March 1, 2020, to June 1, 2020. Data were collected from nursing care reports and clinical discharge reports. Included patients were 18 years or older, had a hospital length of stay of 1 day or longer, and were hospitalized in an internal medicine unit. Surgical and traumatic wounds and pediatric patients were excluded.

RESULTS

A total of 116 patients and 216 wounds were included. The overall wound prevalence was 7.6%, and incidence was 3.5% in the internal medicine units. Pressure injuries (PIs) were the most common wound type, and patients with COVID-19 had significantly higher PI risk (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-4.0; P = .042). Significant differences in PI staging were noted: 83.2% of wounds in patients with COVID-19 were stages I-II versus 67.8% in patients without COVID-19; the probability of stage III-IV PIs among patients without COVID-19 was doubled (OR, 2.3; 95% CI, 1.2-4.5; P = .009). The probability of acute wounds tripled in patients with COVID-19 (OR, 3.7; 95% CI, 2.1-6.6; P < .001). Patients with COVID-19 also had longer mean hospital stays and higher ICU admission rates. No case fatality rate differences were observed.

CONCLUSIONS

In this context of clinical practice, protocolized assessment and implementation of preventive measures must be ensured among older adult populations, patients with associated comorbidities, and ICU patients.

Singular Predictors of Hospital-Acquired Pressure Injuries Under Intensive Care: A Retrospective Cohort Study in a Medium-Complexity Hospital

A retrospective cohort study of hospital-acquired pressure injuries (HAPI) reported an incidence rate of 34.3% based on 582 medical records of adult patients admitted to the intensive care unit (ICU) of a medium-complexity public hospital in 2017 and 2018. Sixty percent of the patients used respirators, 49.3% presented hypotension, and 48.1% used norepinephrine. The main individual predictors of HAPI in the ICU were "days of norepinephrine" with an odds ratio (OR) of 1.625 (95% CI: 1.473-1.792) and concordance statistic (AUC) of 0.818 (95% CI: 0.779-0.857), "days of mechanical ventilation" with an OR of 1.521 (1.416-1.634) and AUC of 0.879 (0.849-0.909), "ICU stay (days)" with an OR of 1.279 (1.218-1.342) and AUC of 0.846 (0.812-0.881), and "Braden's sensory perception" with an OR of 0.345 (95% CI: 0.278-0.429) and AUC of 0.760 (0.722-0.799). The duration of mechanical ventilation, norepinephrine administration, and ICU length of stay presented significant discriminative capacity for HAPI prediction.

Implementation of Pressure Injury Prevention Strategies in Acute Care: Results From the 2018-2019 International Pressure Injury Prevalence Survey

PURPOSE

The purpose of this study was to evaluate the implementation of pressure injury (PI) prevention strategies in adult acute care settings in the United States using the data from the 2018/2019 International Pressure Ulcer Prevalence (IPUP) Survey.

DESIGN

Observational, cohort study with cross-sectional data collection and retrospective data analysis.

SUBJECTS AND SETTING

The sample comprised 296,014 patients hospitalized in 1801 acute care facilities in the United States that participated in the 2018 and/or 2019 IPUP Survey. Slightly less than half (49.4%, n = 146,231) were male, 50% (n = 148,997) were female, 0.6% (n = 17,760) were unknown. Their mean age was 64.29 (SD 17.2) years.

METHODS

Data from the 2018/2019 IPUP database were analyzed to evaluate the implementation of prevention strategies including repositioning, support surface use, head-of-bed (HOB) elevation, heel elevation, moisture management, minimizing linen layers, and nutritional support. Practices were analyzed for differences between patients without pressure injuries, and patients with Stage 1 and 2 hospital-acquired pressure injury (HAPI), and those with severe HAPIs (Stage 3, Stage 4, unstageable, and deep tissue pressure injury). Acute care unit types included critical or intensive care units, medical-surgical inpatient care units, and step-down units.

RESULTS

Compliance rates to PI prevention strategies varied among patients at risk for HAPIs (Braden Scale for Pressure Sore Risk score ≤18). Daily skin assessment was performed for 86% of patients with no HAPIs and 96.8% of patients with severe HAPIs. Pressure redistribution was used in 74.6% of all patients and in over 90% of patients with severe HAPIs; however, compliance to routine repositioning was reported at lower levels between 67% and 84%, respectively. Heel elevation was reported for over 60% of the patients with severe HAPIs while 31.9% did not receive heel elevation, though only 6% were reported as not needing elevation. The majority of patients had HOB greater than the 30° at the time of the data collection; compliance with minimizing linen layers (≤3) was reported in 76% or more. Moisture management strategies were reportedly used in more than 71% of all patients and 89% for patients with severe HAPIs. Nutrition support was used for 55% to 82% of the patients and only documented as contraindicated in fewer than 2% of all groups.

CONCLUSION

Study findings revealed substantial compliance rates to PI prevention strategies. Nevertheless, there is potential for improvement in the implementation of some of the most basic prevention strategies including repositioning, heel elevation, nutritional support, and moisture management.

Biomarkers for the early detection of pressure injury: A systematic review and meta-analysis

BACKGROUND

Pressure injury imposes a significant burden for patients and healthcare systems and the majority of pressure injuries are preventable. The early identification of pressure injury is critical for its prevention. As an objective measure, biomarkers have preliminarily shown the potential to identify individuals at risk for developing pressure injury before it is visually observed to occur. However, these results have not been synthesized.

OBJECTIVE

To assess and synthesise the predictive effect of different biomarkers in the early detection of pressure injury formation.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, CINAHL Complete and the Cochrane Library were comprehensively searched for articles up to June 2021. No restrictions were applied to study design type, language, country, race or date of publication.

REVIEW METHODS

Two reviewers independently extracted data from all original eligible studies using a specified data extraction form, resolved disagreements through discussion and the involvement of an additional reviewer. Methodological quality of all included studies was independently appraised by two authors with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and the Newcastle-Ottawa Quality Assessment Scale (NOS). Heterogeneity of each study was estimated using the I² statistic, and the data was synthesized using StataSE15.

RESULTS

Eight observational studies involving 10595 participants were included. The overall pooled area under curve (AUC) and the 95% confidence intervals (CIs) of Serum albumin (Alb) was 0.66(0.62-0.70), and the Serum haemoglobin (Hb) was 0.67(0.60-0.74). The AUC and 95% CI of C-reactive protein (CRP) was 0.62(0.50-0.74), Braden score was 0.56 (0.429-0.691), Waterlow score was 0.729(0.654-0.803), Alb with Waterlow was 0.741(0.694-0.787), and the combination of Hb, CRP, Alb, Age and Gender was 0.79(0.682-0.898). Besides, the chemokine interferon-γ-induced protein of 10kd/CXCL10, cytokine interferon-α, tumor necrosis factor-alpha (TNF-α), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-15 (IL-15) and combination of creatine kinase (CK), myoglobin (Mb), heart-type fatty acid binding protein (H-FABP) and CRP may prove potential for detecting pressure injury.

CONCLUSION

The findings suggest the combination of Hb, CRP, Alb, Age and Gender is superior to other biomarkers. However, the predictive effect of biomarkers needs to be confirmed by more researches and patient-level data.

EXPLORING SENTIMENT AND CARE MANAGEMENT OF HOSPITALIZED PATIENTS DURING FIRST WAVE OF COVID-19 PANDEMIC USING ELECTRONIC NURSING HEALTH RECORDS: DESCRIPTIVE STUDY

BACKGROUND

The COVID-19 pandemic has changed the usual work in many hospitalization units (or wards). Few studies use electronic nursing clinical notes (ENCN) and their unstructured text to identify alterations in patients' feelings and therapeutic procedures of interest.

OBJECTIVE

Analysis of positive/negative sentiments through inspection of the free text of the ENCN; comparison of sentiments of ENCN with/without hospitalized COVID-19 patients; temporal analysis of the sentiments of the patients during the start of the first wave of the COVID-19 pandemic; and identification of the topics in ENCN.

METHODS

This is a descriptive study with analysis of the text content of ENCN. All ENCNs between January and June 2020 at Guadarrama Hospital (Madrid, Spain) extracted from the CGM Selene Electronic Health Records System were included. Two groups of ENCNs were analyzed: one from hospitalized patients in post intensive care units COVID-19, and a second group from hospitalized patients with non COVID-19. A sentiment analysis was performed on the lemmatized text, using the dictionaries NRC, Affin and Bing. A polarity analysis of the sentences was performed using the Bing dictionary, the SO Dictionaries V1.11Spa dictionary as amplifiers and decrementators. Machine learning techniques were applied in order to evaluate the presence of significant differences in the ENCN in groups of COVID-19 or non COVID-19 patients. Finally, a structural analysis of thematic models was performed to study the abstract topics that occur in the ENCN, using Latent Dirichlet Allocation topic modeling.

RESULTS

A total of 37,564 electronic health records were analyzed. Sentiment analysis in ENCN showed that patients with subacute COVID-19 have a higher proportion of positive sentiments compared to non COVID-19. Also, there are significant differences in polarity between both groups (Z=5.532, P<.001) with a polarity in COVID-19 patients of 0.108±0.299 versus a polarity in non COVID-19 patients of 0.09±0.301. Machine learning modeling reported that despite all models presenting high values, it is the neural network that presents the best indicators, over 0.8, and with significant P values between both groups. From Structural Topic Modeling analysis, the final model containing 10 topics was selected. It is noted a high correlation between topics 2, 5 and 8 (pressure ulcer and pharmacotherapy treatment), topics 1, 4, 7 and 9 (incidences related to fever and well-being state, and baseline oxygen saturation) and topics 3, 10 (blood glucose level and pain).

CONCLUSIONS

The ENCN may help in the development and implementation of more effective programs which allows to the COVID-19 pandemic patients a faster come back to a pre-pandemic way of life. Topic modeling could help identify specific clinical problems in patients and better target the care they receive.

CLINICALTRIAL

A Cartoon Version of Braden Scale to Assess the Risk of Pressure Injury: Content Validity and Interrater Reliability Study

INTRODUCTION

The Braden Scale is widely used to assess the risk of pressure injury. However, the vague literal description of the items creates difficulties for bedside nurses and limits its sensitivity. To solve this problem, we developed a cartoon version of the Braden scale (CVBS) to improve the pressure injury risk assessment ability of bedside nurses.

METHODS

The CVBS was constructed by two nurses, and the final version was determined through a two-round Delphi consultation. The scale's content validity was calculated based on expert ratings. A total of 265 patients were evaluated simultaneously with the CVBS by 119 bedside nurses and 46 wound care specialists; and 114 bedside nurses and the same 46 wound care specialists evaluated 239 patients with the original Braden scale (OBS). The interrater reliability between the two groups was calculated as Kappa value, and then the Kappa values of the two versions were compared.

RESULTS

The content validity for the draft scale was not good enough. After modification, the indices of all the items in the final CVBS reached 1.00. The Kappa value of the OBS was 0.69 (95% CI 0.61-0.76); for each item, it ranged from 0.60 to 0.80. The interrater reliabilities of the CVBS were higher than those of the OBS, with an overall kappa value of 0.87 (95% CI 0.81-0.92) and a range of 0.77 to 0.93 for each item. The differences between the Kappa values of the CVBS and those of the OBS were all statistically significant.

CONCLUSIONS

The CVBS had good validity and showed higher interrater reliability than the OBS, indicating that it may improve bedside nurses' ability to assess pressure injury risk.

Risk factors for hospital-acquired and community-acquired pressure injuries: a multicentre mixed case-control study

OBJECTIVES

To separately examine and comprehensively compare the risk factors for hospital-acquired (HAPIs) and community-acquired pressure injuries (CAPIs).

DESIGN

A mixed case-control study.

SETTING

Four medical centres in China.

PARTICIPANTS

Inclusion criteria included patients who were (1) aged ≥18 years on admission; (2) admitted between January 2014 and December 2018, and (3) diagnosed with HAPIs (cases) or with no HAPIs (controls) during hospitalisation in the HAPIs study, and confirmed with CAPIs (cases) or with no PIs (controls) on admission in the CAPIs study. The exclusion criteria were as follows: (1) admitted for childbirth, psychiatric reasons or rehabilitation; (2) admitted for observation; (3) transferred from another hospital and (4) confirmed to have suffered PIs from previous hospitalisations in the CAPIs study. In total, 320 cases and 1657 controls were included in the HAPIs study, and 1763 cases and 1786 controls were included in the CAPIs study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variable was the occurrence of PIs.

RESULTS

The existence of PIs or scars from previous PIs on admission, presence of forced posture, use of medical devices and surgery during hospitalisation were found to be independent risk factors for HAPIs, as evidenced by the corresponding OR and 95% CI values of 51.931 (34.241 to 78.763), 2.006 (1.405 to 2.864), 3.226 (1.709 to 6.089) and 2.161 (1.452 to 3.215), respectively. Age, sex, Braden rating and diabetes were found to be independent risk factors for CAPIs, as evidenced by the corresponding OR and 95% CI values of 1.031 (1.026 to 1.036), 0.810 (0.698 to 0.941), 1.235 (1.167 to 1.307) and 2.059 (1.332 to 3.184), respectively.

CONCLUSIONS

The existence of PIs or scars from previous PIs on admission, presence of forced posture, use of medical devices and surgery during hospitalisation are suggested to be included as independent items for the risk assessment of PIs, together with the Braden scale. The Braden rating plays different roles in the development of CAPIs and HAPIs.

Modeling Patient Risk for Hospital-Acquired Pressure Injuries During COVID-19: A Retrospective Study

BACKGROUND

COVID-19 negatively impacts many organ systems including the skin. One of the most significant skin-associated adverse events related to hospitalization are pressure injuries.

PURPOSE

The aim of this study was to determine 8 risk factors that would place hospitalized patients at a higher risk for hospital-acquired pressure injuries (HAPIs) during the COVID-19 pandemic.

METHODS

A retrospective, descriptive analysis was conducted in an urban academic health science center located in the southeastern United States.

RESULTS

There were 247 of 23 093 patients who had pressure injuries and 1053 patients who had a positive COVID-19 diagnosis. Based on the generalized estimating equation model, diagnosis of COVID-19, age, male gender, risk of mortality, severity of illness, and length of stay are statistically significant factors associated with the development of HAPIs.

CONCLUSIONS

Further study should explore pathology of COVID-19 skin changes and what interventions are effective against HAPIs in the COVID-19 population taking into consideration current treatments.

Factors affecting the incidence and prevalence of pressure ulcers in COVID-19 patients admitted with a Braden scale below 14 in the intensive care unit: Retrospective cohort study

The pandemic of coronavirus (COVID‐19) has significantly increased the admission of patients with extensive complications, especially for respiratory support, to intensive care units (ICUs) worldwide. These patients also suffer from pressure ulcers (PUs) as another complication that occurs due to increased length of hospitalisation and acute conditions of patients. Therefore, this study aimed to evaluate the incidence and prevalence of PU and the factors affecting it in COVID‐19 patients admitted to ICUs. This cohort retrospective study used registry data in Imam Reza Hospital located in west of Iran. Four hundred and forty‐five COVID‐19 patients older than 20 years hospitalised in corona ICUs from 20 March 2020 to 30 December 2020, with a Braden score of less than 14 were included in the study. To investigate the relationship between variables in rate prevalence, univariate logistic regression analysis was used to calculate odds ratio, and for incidence rate in estimating PU risk generated in ICUs, hazard ratio was calculated using cox regression. One hundred and eighty‐three (41.12%) patients were male. The mean age of patients was 63 (SD = ±9.78) years. A total of 1152 cases of PU were generated, with the highest prevalence of PU with 234 cases in the sacrum. One hundred and seventy‐six (55.87%) patients underwent non‐invasive ventilation ulcers. The prevalence of PU was 79.7%. The highest prevalence was found in people over 80 years with 90.67%. The incidence ratio was 46.74%. The highest number of new cases was seen in diabetic patients with 60.96%. First‐degree ulcers were the most common degree of ulceration in 252 (55.38%) patients. Incidence and prevalence excluding first‐degree wounds were 24.04% and 49.66%, respectively. Age, Braden score, BMI, comorbidity, diabetes mellitus, stool incontinence, Glasgow coma scale, vasopressor, and length of hospital stay were significantly associated with PU (P < .05). The incidence and prevalence of PU in patients were high in this study. The length of hospitalisation and Braden score were the most important factors in the development of PU. The widespread prevalence of COVID‐19 and the relatively long stay of patients in the ICU created unfavourable conditions for patients and the treatment system, therefore, it emphasised the use of appropriate measures to prevent PU to avoid double costs and longer stays.

Translation and piloting of the Chinese Mandarin version of an intensive care-specific pressure injury risk assessment tool (the COMHON Index)

Objective

Methods

Results

Conclusions

Malnutrition and Pressure Injury Risk in Vulnerable Populations: Application of the 2019 International Clinical Practice Guideline

ABSTRACT

Nutrition plays a vital role in promoting skin integrity and supporting tissue repair in the presence of chronic wounds such as pressure injuries (PIs). Individuals who are malnourished are at greater risk of polymorbid conditions, adverse clinical outcomes, longer hospital lengths of stay, PI development, and mortality, and incur increased healthcare costs compared with patients who are adequately nourished. In addition, some patient populations tend to be more vulnerable to PI formation, such as neonates, patients with obesity, older adults, and individuals who are critically ill. Accordingly, this article aims to review the latest nutrition care recommendations for the prevention and treatment of PIs, including those recommendations tailored to special populations. A secondary objective is to translate nutrition recommendations into actionable steps for the healthcare professional to implement as part of a patient plan of care.Implementing an evidence-based plan of care built around individualized nutrition interventions is an essential step supporting skin integrity for these populations. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG) affirms that meeting nutrient requirements is essential for growth, development, maintenance, and repair of body tissues. Many macronutrients and micronutrients work synergistically to heal PIs. Registered dietitian nutritionists play an important role in helping patients identify the most nutrient dense foods, protein supplements, and oral nutrition supplements to meet their unique requirements.

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings.

REVIEW METHOD USED

This is a systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Five databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019.

REVIEW METHODS

From an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care-specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate.

RESULTS

Overall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I² = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I² = 0%) and heel (risk ratio = 0.31, p = 0.02; I² = 0%) prophylactic dressings for pressure injury prevention.

CONCLUSIONS

Only prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care-specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

Meta-analysis, using PRISMA guidelines.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Heterogeneity hampers the identification of general pressure injury risk factors in intensive care populations: A predictive modelling analysis

OBJECTIVE

To determine risk factors for pressure injury in distinct intensive care subpopulations according to admission type (Medical; Surgical elective; Surgery emergency; Trauma/Burns).

METHODOLOGY/DESIGN

Predictive modelling using generalised linear mixed models with backward elimination on prospectively gathered data of 13 044 adult intensive care patients.

SETTINGS

1110 intensive care units, 89 countries worldwide.

MAIN OUTCOME MEASURES

Pressure injury risk factors.

RESULTS

A generalised linear mixed model including admission type outperformed a model without admission type (p = 0.004). Admission type Trauma/Burns was not withheld in the model and excluded from further analyses. For the other three admission types (Medical, Surgical elective, and Surgical emergency), backward elimination resulted in distinct prediction models with 23, 17, and 16 predictors, respectively, and five common predictors only. The Area Under the Receiver Operating Curve was 0.79 for Medical admissions; and 0.88 for both the Surgical elective and Surgical emergency models.

CONCLUSIONS

Risk factors for pressure injury differ according to whether intensive care patients have been admitted for medical reasons, or elective or emergency surgery. Prediction models for pressure injury should target distinct subpopulations with differing pressure injury risk profiles. Type of intensive care admission is a simple and easily retrievable parameter to distinguish between such subgroups.

Quality Improvement Intervention Bundle Using the PUPPIES Acronym Reduces Pressure Injury Incidence in Critically Ill Patients

OBJECTIVE

To assess whether a quality improvement bundle focusing on prevention is effective in reducing pressure injury (PI) incidence or costs or delaying PI onset.

METHODS

A combined retrospective/prospective cohort study was performed at an academic tertiary care ICU on all patients admitted with a length of stay longer than 48 hours and Braden scale score of 18 or less. Following retrospective data collection (preintervention), a multimodal quality improvement bundle focusing on PI prevention through leadership initiatives, visual tools, and staff/patient education was developed, and data were prospectively collected (postintervention).

RESULTS

Statistical and cost analyses were performed comparing both cohorts. A total of 930 patients met the study inclusion criteria (preintervention, n = 599; postintervention, n = 331). A significant decrease in PI incidence was observed from preintervention (n = 37 [6%]) to postintervention (n = 7 [2%], P = .005). This led to a predicted yearly cost savings of $826,810. Further, a significant increase in time to PI occurrence was observed from preintervention (mean, 5 days) to postintervention (mean, 9 days; P = .04). Staff were compliant with the bundle implementation 80% of the time.

CONCLUSIONS

Implementation of the quality improvement bundle focused on multimodal PI prevention in critically ill patients led to a significant reduction in PI incidence, increased time to PI occurrence, and was cost-effective.

The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BACKGROUND

The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU).

METHODS

A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient.

RESULTS

The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients' positions, including the prone position; five suggested specific screening tools and patients' factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings.

CONCLUSIONS

The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.

Risk Factors for Pressure Injuries in Adult Patients: A Narrative Synthesis

Pressure injuries remain a serious health complication for patients and nursing staff. Evidence from the past decade has not been analysed through narrative synthesis yet. PubMed, Embase, CINAHL Complete, Web of Science, Cochrane Library, and other reviews/sources were screened. Risk of bias was evaluated using a slightly modified QUIPS tool. Risk factor domains were used to assign (non)statistically independent risk factors. Hence, 67 studies with 679,660 patients were included. In low to moderate risk of bias studies, non-blanchable erythema reliably predicted pressure injury stage 2. Factors influencing mechanical boundary conditions, e.g., higher interface pressure or BMI < 18.5, as well as factors affecting interindividual susceptibility (male sex, older age, anemia, hypoalbuminemia, diabetes, hypotension, low physical activity, existing pressure injuries) and treatment-related aspects, such as length of stay in intensive care units, were identified as possible risk factors for pressure injury development. Health care professionals' evidence-based knowledge of above-mentioned risk factors is vital to ensure optimal prevention and/or treatment. Openly accessible risk factors, e.g., sex, age, BMI, pre-existing diabetes, and non-blanchable erythema, can serve as yellow flags for pressure injury development. Close communication concerning further risk factors, e.g., anemia, hypoalbuminemia, or low physical activity, may optimize prevention and/or treatment. Further high-quality evidence is warranted.

Pressure Injuries in Critical Care Patients in US Hospitals: Results of the International Pressure Ulcer Prevalence Survey

PURPOSE

The purpose of this secondary analysis was to examine pressure injury (PI) prevalence, PI risk factors, and prevention practices among adult critically ill patients in critical care units in the United States using the International Pressure Ulcer Prevalence™ (IPUP) Survey database from 2018 to 2019.

DESIGN

Observational, cohort study with cross-sectional data collection and retrospective data analysis.

SUBJECTS AND SETTING

The sample comprised 41,866 critical care patients drawn from a sample of 296,014 patients in US acute care facilities who participated in the 2018 and/or 2019 IPUP surveys. The mean age among critical care patients was 63.5 years (16.3) and 55% were male. All geographic regions of the United States were represented in this sample, with the greatest percentages from the Southeast (47.5%) and Midwest (17.5%) regions.

METHODS

Overall critical care PI prevalence and hospital-acquired PI (HAPI) rates were obtained and analyzed using the 2018/2019 IPUP survey database. Critical care PI risk factors included in the database were analyzed using frequency distributions. Prevention practices among critically ill patients were analyzed to evaluate differences in practices between patients with no PIs, superficial PIs (stage 1, stage 2), and severe PIs (stage 3, stage 4, unstageable, deep tissue pressure injury).

RESULTS

The overall PI prevalence for critical care patients was 14.3% (n = 5995) and the overall HAPI prevalence was 5.85% (n = 2451). In patients with severe HAPIs, the most common risk factors were diabetes mellitus (29.5%), mechanical ventilation (27.6%), and vasopressor agents (18.9%). Significant differences between patients with no PIs as compared to those with superficial or severe HAPIs (P = .000) for all prevention practices were found.

CONCLUSIONS

Study findings support the gaps elucidated in previous critical care studies on PI development in this population. The 2 most persistent gaps currently challenging critical care practitioners are (1) accurate risk quantification in this population and (2) the potential for unavoidability in PI development among critically ill patients.

Frequency of and risk factors for intensive care unit-acquired sacrum pressure injuries in critically ill patients: A multicenter cross-sectional study in China

RATIONALE AIMS AND OBJECTIVES

Hospital-acquired pressure injuries (HAPI) prolong hospital stays and are an important health problem worldwide. The aim of this study was to assess the frequency of and risk factors for intensive care unit (ICU)-acquired pressure injuries (IAPI) on the sacrum in critically ill patients in China.

METHODS

We performed a multicenter, cross-sectional survey of IAPI on the sacrum in 23 adult ICUs in 19 hospitals in China. Data for 421 critically ill patients were collected on December 13, 2019, and January 13, 2020, including patient characteristics, physiological, and clinical information. Logistic regression was used to analyze the risk factors for IAPI on the sacrum in the ICU.

RESULTS

Forty-one patients presented sacrum pressure injuries in the ICU, with a frequency of 9.74%. Risk factors that significantly increased the risk of IAPI on the sacrum were lower body mass index (BMI, odds ratio [OR] = 1.115, confidence interval [CI]: 1.011-1.229, P = .029), chronic obstructive pulmonary disease (COPD, OR = 3.183, CI: 1.261-8.037, P = .014), multiple organ dysfunction syndrome (MODS, OR = 2.670, CI: 1.031-6.903, P = .043), and a lower Braden risk score (OR = 1.409, CI: 1.197-1.659, P < .001).

CONCLUSION

Lower BMI, COPD, MODS, and lower Braden risk score are independent risk factors for sacrum IAPI in China.

Evidence-based review of the effects of nutritional supplementation for pressure ulcer prevention

The objective of this evidence-based review was to explore whether the evidence supports the use of nutritional supplements in pressure ulcer (PU) prevention strategies. Several electronic databases, including Ovid MEDLINE (1946 to May week 32 019), Ovid EMBASE (1947 to May 28, 2019), EBSCO CINAHL (until June 13, 2019), Scopus (until July 9, 2019), and the Web of Science (until June 13, 2019) were searched. No limitation was placed on the year of publication. Studies considered for inclusion were those with adult populations, and only English language texts with available full text were reviewed. AMSTAR (a measurement tool to assess systematic reviews) was used to evaluate the quality of the studies included in the systematic review. The Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence was used to assess the level of evidence. Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) was used to assess guideline article, and Appraisal tool for Cross-Sectional Studies (AXIS) was also used for cross-sectional studies. The search identified 1761 studies. After the application of inclusion and exclusion criteria, 24 studies were retained of various designs, including 10 systematic reviews, five clinical reviews, three randomised controlled trials, two observational studies, one quasi-experimental study, one cross-sectional study, one cohort study, and one Clinical Guideline. Two were rated as high-quality reviews, 14 were rated as moderate-quality reviews, five were rated as low-quality reviews, and three were rated as critically low-quality reviews. The majority of the reviewed studies were of low-to-moderate quality because of biases in the study design and incomplete data reporting, which did not fulfil the reporting criteria of the appraisal tools. However, the majority of the studies showed a reduction in PU incidence after nutritional supplement though not significant. Whether the use of pharmacological appraisal tools to assess non-pharmacological studies is appropriate is unclear. Regardless of the low-to-moderate quality of the studies in this review, nutritional supplements appear to play a role in PU prevention.

Pressure Injury Prevalence in Acute Care Hospitals With Unit-Specific Analysis: Results From the International Pressure Ulcer Prevalence (IPUP) Survey Database

PURPOSE

The purpose of this study was to determine overall pressure injury (PI) prevalence and hospital-acquired pressure injury (HAPI) prevalence in US acute care hospitals. Additionally, analysis of patient characteristics associated with HAPIs will be presented.

DESIGN

Observational, cross-sectional cohort study.

SUBJECTS AND SETTING

An in-depth analysis of data was performed from the International Pressure Ulcer Prevalence™ (IPUP) Survey database for years 2018-2019 that included 296,014 patients. There were 914 participating US acute care facilities in 2018 and 887 in 2019. Overall PI prevalence and HAPI prevalence over time were also examined for 2006-2019 acute care data from 2703 unique facilities (1,179,108 patients).

METHODS

Overall PI prevalence and HAPI prevalence were analyzed from the 2006-2019 IPUP survey database. Recent data for 2018-2019 PI prevalence are reported separately for medical-surgical, step-down, and critical care unit types. PI stages, anatomic locations, Braden score associated with HAPIs, and body mass index were analyzed.

RESULTS

Overall PI prevalence and HAPI prevalence data declined between 2006 and 2019; however, the prevalence plateaued in the years 2015-2019. Data from 2018 to 2019 (N = 296,014) showed that 26,562 patients (8.97%) had at least one PI and 7631 (2.58%) had at least one HAPI. Patients cared for in medical-surgical inpatient care units had the lowest overall PI prevalence (7.78%) and HAPI prevalence (1.87%), while critical care patients had the highest overall PI prevalence (14.32%) and HAPI prevalence (5.85%). Critical care patients developed more severe PIs (stage 3,4, unstageable, and deep-tissue pressure injuries [DTPIs]), which were proportionally higher than those in the step-down or medical-surgical units. The sacrum/coccyx anatomic location had the highest overall PI prevalence and HAPI prevalence, except for DTPIs, which most common occurred on the heel.

CONCLUSIONS

Overall and HAPI prevalence has plateaued 2015-2019. Prevalence of HAPIs, especially in critical care units, remain high. While medical advancements have improved survival rates among critically ill patients, survival may come with unintended consequences, including PI development.

Risk factors for heel pressure injury in cardiovascular intensive care unit patients

This study analyzed the risk factors for heel pressure injury in cardiovascular intensive care unit patients with the aim of laying the groundwork for preventive nursing interventions. We conducted a retrospective case‐control study of 92 patients who were admitted to the cardiovascular surgical or medical intensive care unit of a university hospital in South Korea between January and December 2017. Of these patients, 31 and 61 were included to the heel pressure injury group and the non‐heel pressure injury group, respectively. Data on their demographic, disease‐related, and intensive care unit treatment characteristics, as well as the degree of pressure injury, were collected from the hospital's electronic medical records using a standardized form. Cardiac surgery (P < .001), operation time (P = .001), use of a mechanical ventilator (P < .001), use of vasoconstrictors (P < .001), use of sedative drugs (P < .001), and extracorporeal membrane oxygenation treatment (P < .001) were identified as significant risk factors for heel pressure injury. A total of 22 patients (71%) from the heel pressure injury group developed deep tissue injury, and 16 patients (51.6%) who received extracorporeal membrane oxygenation treatment developed heel pressure injury.

Incidence of pressure injuries and risk factors in a paediatric surgical intensive care unit: a prospective cohort study

OBJECTIVES

The aim of the study was to evaluate the incidence of, and risk factors for, the occurrence of pressure injuries (PIs) in a paediatric surgical intensive care unit (ICU).

METHOD

This is a prospective cohort study of 153 children in the postoperative period. Patients were assessed daily by physical examination and data were collected. All independent variables were included in a logistic regression.

RESULTS

The mean age of the cohort was 2 years, and the incidence of PI was 15.7%. According to the Braden Q Scale, 58.2% of patients were at high risk of developing PI; 79.3% of PIs were related to immobility and 69.0% were at stage 1. Risk factors were ICU length of stay and the number of medical devices used.

CONCLUSION

The incidence of PI was high because patients were mostly at a considerable risk of developing a PI. PI was associated with several factors, especially length of ICU stay and number of devices, both of which are indirect indicators of the severity of patient condition and healthcare costs.

Risk Factors Associated With Pressure Ulcers in Patients With Traumatic Brain Injury Admitted to the Intensive Care Unit

Pressure injuries (PIs) are one of the most important and frequent complications in patients admitted to the intensive care unit (ICU) or those with traumatic brain injury (TBI). The purpose of this study was to determine the incidence and risk factors of PIs in patients with TBI admitted to the ICU. In this retrospective study, the medical records of 237 patients with TBI admitted to the trauma ICU of a university hospital were examined. Demographic, trauma-related, and treatment-related characteristics of all the patients were evaluated from their records. The incidence of PIs was 13.9%, while the main risk factors were a higher injury severity score, use of mechanical ventilation, vasopressor infusion, lower Braden Scale score, fever, and period of enteral feeding. This study advances the nursing practice in the ICU by predicting the development of PIs and their characteristics in patients with TBI.

Effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination.

OBJECTIVE

Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019.

METHODS

Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data.

RESULTS

Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I² = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I² = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I² = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I² = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I² = 36%).

CONCLUSIONS

Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number:CRD42019129556.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19)

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ²  =  22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ²  =  13.26, P  =  .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."

Use of multilayer silicone foam dressings as adjuvant therapy to prevent pressure injuries

Despite progress in the prevention of pressure injuries (PIs), they remain a challenging public health problem because of their frequency and morbidity. Protection of the skin by multilayer silicone foam dressings may be an adjuvant measure to prevent PIs in high-risk patients. Despite the available clinical data and published recommendations on this measure, caregivers face difficulties in identifying patients who would benefit from this adjuvant measure. The objective of this work was to define the profiles of high-risk patients who would benefit optimally from this measure in combination with basic preventive procedures. This consensual expert opinion was drawn up using two methods: the Nominal Group Technique with eight medical and paramedical experts, and the Delphi process with 16 experts. The bases for this expert consensual opinion were a formal search and analysis of the published literature regarding evidence on the prevention of PIs using multilayer silicone foam dressings. The consensual expert opinion reported here addresses five proposals mostly intended to define patients who would benefit from the use of a multilayer silicone foam dressing (≥4 layers) to prevent PIs (sacrum and heels).

Links between autophagy and tissue mechanics

Physical constraints, such as compression, shear stress, stretching and tension, play major roles during development, tissue homeostasis, immune responses and pathologies. Cells and organelles also face mechanical forces during migration and extravasation, and investigations into how mechanical forces are translated into a wide panel of biological responses, including changes in cell morphology, membrane transport, metabolism, energy production and gene expression, is a flourishing field. Recent studies demonstrate the role of macroautophagy in the integration of physical constraints. The aim of this Review is to summarize and discuss our knowledge of the role of macroautophagy in controlling a large panel of cell responses, from morphological and metabolic changes, to inflammation and senescence, for the integration of mechanical forces. Moreover, wherever possible, we also discuss the cell surface molecules and structures that sense mechanical forces upstream of macroautophagy.

Comparing Risk Profiles in Critical Care Patients With Stage 2 and Deep Tissue Pressure Injuries: Exploratory Retrospective Cohort Study

BACKGROUND

Understanding hospital-acquired pressure injury (HAPrI) etiology is essential for developing effective preventive interventions. Pressure injuries are classified based on the degree of visible tissue damage; the two most commonly identified HAPrI stages in critical care patients are stage 2 and deep tissue injury (DTI). Some experts speculate that stage 2 and DTI have different etiologies, with stage 2 injuries formed from the "outside in" as a result of tissue deformation, decreased perfusion, and subsequent ischemia caused by external pressure and/or shear forces, whereas DTI emerges from the "inside out" due to inadequate perfusion to the deeper tissues causing tissue ischemia.

OBJECTIVE

The purpose of this study was to compare risk profiles of intensive care unit (ICU) patients who developed stage 2 injuries versus DTIs.

METHODS

This was a retrospective cohort study to compare the risk profiles of patients in the ICU with stage 2 injuries and DTIs using electronic health record data. Eligible patients were admitted to the surgical or cardiovascular ICU at an academic medical center in the United States between 2014 and 2018. Anatomic locations were examined, and differences in anatomic patterns were compared using the χ2 test. Risk profile variables included demographic characteristics, Braden Scale scores, vasopressor infusions, hypotension, surgical factors, length of stay, BMI, laboratory values, diabetes, Charlson Comorbidity Index, and the levels of sedation or agitation. The distributions of potential risk variables between patients with stage 2 injuries and DTIs were summarized and compared. A logistic regression model with the least absolute shrinkage and selection operator method was developed to identify the critical risk factors for distinguishing stage 2 and DTI patients.

RESULTS

A total of 244 patients developed a stage 2 injury or DTI during the study period. Of those, 38 patients with medical device-related pressure injury were excluded. The final study sample consisted of 206 patients (n=146 stage 2 and n=60 DTI). Compared with DTIs, stage 2 HAPrIs were more likely to be located on a bony prominence (n=206, χ21=8.43, P=.03). The multivariate model showed that patients who developed stage 2 HAPrIs had a longer length of stay in the ICU than those with DTIs (odds ratio [OR] 1.001, 95% CI 1-1.002, P=.03) but were less likely than patients with DTIs to experience a diastolic blood pressure <50 mmHg (OR 0.179, 95% CI 0.072-0.416, P<.001) or receive an epinephrine infusion (OR 0.316, 95% CI 0.079-0.525, P=.008).

CONCLUSIONS

Stage 2 injuries and DTIs have different risk factors and different anatomic patterns. Patients who developed DTIs were more likely to experience low diastolic blood pressure and receive epinephrine, a potent vasopressor. Stage 2 injuries were more likely to occur on the bony prominences, whereas DTIs commonly occurred on the fleshy parts of the body such as the buttock.

Construction of a Risk Prediction Model for Intraoperative Pressure Injuries: A Prospective, Observational Study

PURPOSE

To explore the incidence and risk factors of intraoperatively acquired pressure injuries (IAPIs) in patients transferred to the intensive care unit (ICU) after surgery and establish a risk factor prediction model for IAPIs for guiding clinical intervention.

DESIGN

A prospective, observational study was conducted.

METHODS

This study was conducted in the West China Hospital of Sichuan University. A total of 648 patients who were transferred to the ICU after surgery were recruited from May 1, 2019, to October 30, 2020. Data were collected preoperatively, intraoperatively, and postoperatively (3 days after transfer to the ICU). The enrolled patients underwent well-developed preventive measures to prevent IAPIs in the operating room and ICU. A sociodemographic and clinical characteristic questionnaire, the Braden pressure injuries risk assessment scale, the activity of daily living scale, and the Nutrition Risk Screening-2002 were used. Descriptive, bivariate, and logistic regression analyses were conducted.

FINDINGS

The incidence rate of IAPIs within 3 days was 18.67%. The Braden pressure injuries score, preoperative fasting blood glucose level, emergency surgery, and types of vasoactive drugs in the ICU were significant factors for increased risk. The risk factor prediction model was established using the perioperative Braden pressure injuries score (P = 0.027, odds ratio [OR] = 0.901), preoperative fasting blood glucose level (P = 0.027, OR = 1.111), emergency surgery (P < 0.01, OR = 5.054), types of vasoactive drugs in the ICU (P = 0.038, OR = 1.668), and surgery time (P = 0.021, OR = 2.434). The area under the receiver operating characteristic curve was 0.74; 95% confidence interval was 0.671 to 0.810; sensitivity was 0.635; specificity was 0.860; and the Youden index was 0.495.

CONCLUSIONS

In patients transferred to the ICU after surgery, high fasting blood glucose level before surgery, emergency surgery, types of vasoactive drugs, and surgery time should be treated as predisposing factors in the prevention and control of IAPIs. However, the predictive effect of the perioperative Braden pressure injuries risk assessment scale on the risk of IAPIs needs to be further verified.

Subsequent Pressure Injury Development in Mechanically Ventilated Critical Care Patients with Hospital-Acquired Pressure Injury: A Retrospective Cohort Study

OBJECTIVE

To identify factors associated with subsequent hospital-acquired pressure injury (HAPrI) formation among patients in surgical and cardiovascular surgical ICUs with an initial HAPrI.

METHODS

Patients admitted to a level 1 trauma center and academic medical center in the Western US between 2014 and 2018 were eligible for this retrospective cohort study. Inclusion criteria were development of an HAPrI stage 2 or above, age older than 18 years, the use of mechanical ventilation for at least 24 hours, and documentation of a risk-based HAPrI-prevention plan including repositioning at least every 2 hours. The primary outcome measure was development of a second, subsequent HAPrI stage 2 or higher. Potential predictor variables included demographic factors, shock, Charleston comorbidity score, blood gas and laboratory values, surgical factors, vasopressor infusions, levels of sedation or agitation, Braden Scale scores, and nursing skin assessment data.

RESULTS

The final sample consisted of 226 patients. Among those, 77 (34%) developed a second HAPrI. Independent risk factors for subsequent HAPrI formation were decreased hemoglobin (odds ratio, 0.71; 95% confidence interval [CI], 0.53-0.92; P < .000), vasopressin infusion (odds ratio, 2.20; 95% CI, 1.17-4.26; P = .02), and longer length of stay in the ICU (odds ratio, 1.01; 95% CI, 1.00-1.02; P = .009).

CONCLUSIONS

Patients with an HAPrI are at high risk of subsequent HAPrI development. Anemia, vasopressin infusion, and longer ICU stays are independent risk factors for repeat HAPrI formation.

Pressure wounds in a cohort of critical patients: incidence and associated factors

AIM

To assess the incidence and factors associated with pressure wounds in patients of a Brazilian clinical and surgical Intensive Care Center (composed of three Intensive Care Units).

METHOD

Cohort monitored for clinical and therapeutic variables in an Intensive Care Center. Cox's Multiple Regression was employed, establishing the number of days until the first pressure injury as a time variable; the omnibus test was also performed.

RESULTS

178 patients, 64 (36%) developed at least one pressure wound. The independent variables for the risk of pressure wounds were: Braden <13 (HR: 10.6; 95% CI: 2.5-43.7), history of previous stroke (HR: 2.6; 95% CI: 1.3-5.0), age> 60 years (HR: 2.0; 95% CI: 1.2-3.5), nothing by mouth time (HR: 1.06; 95% CI 1.02 -1.10) and physical therapy days (HR: 0.81; 95% CI: 0.73-0.91).

CONCLUSION

Pressure wounds were incident. Braden <13 points, history of previous strokes, being elderly, and time in nothing by mouth were shown to be independent risk factors for pressure wounds. The days of exposure to physical therapy were protective. These findings corroborate recommendations to monitor the frequency of pressure wounds and to establish protective measures based on local indicators.

Pressure injury prevalence and risk factors in Chinese adult intensive care units: A multi-centre prospective point prevalence study

Despite increasing preventive efforts, pressure injury still occurs in intensive care patients. This study was aimed to describe pressure injury prevalence, risk factors, and prevention practices in adult intensive care patients. This was a multi-centre, one-day, prospective point prevalence study in which a total of 198 intensive care units from 21 provinces in China participated. Overall and ICU-acquired prevalence in intensive care patients were 12.26% and 4.31%, respectively. Consistent with earlier reports, almost half of the ICU-acquired pressure injuries were at stage I, one-fourth were at stage 2, and the most common body sites for pressure injuries were sacral and heel region. Risk factors identified were consistent with prior studies. Repositioning was the most commonly used pressure injury prevention strategy, followed by alternating pressure mattresses/overlays, floating heels, and air-filled mattresses/overlays. These reflect a good level of adherence to recommended international pressure injury prevention clinical practice guidelines. The results provide a baseline reference for overall and ICU-acquired prevalence among adult intensive care patients in China. Future research on what contributed to the lower pressure injury incidence in China needs to be conducted to inform healthcare organisations on their future preventive strategies for pressure injury prevention.

Riesgo de úlceras por presión (UPP) en pacientes internados en las unidades de cuidados intensivos

Introducción: Las limitaciones de la percepción sensorial, la inmovilidad, la sedación, la ventilación mecánica, la hipoperfusión tisular, el edema y la humedad se consideran factores que predisponen la aparición de úlceras por presión en pacientes en estado crítico. Objetivo: Caracterizar las úlceras por presión en pacientes críticos, determinar la asociación con variables demográficas, la hospitalización y las condiciones clínicas, e identificar los factores de riesgo para la aparición de úlceras por presión. Materiales y Métodos: Se realizó un estudio transversal mediante una muestra de pacientes > 18 años que no presentaban úlceras por presión al ingreso y habían estado hospitalizados >24 horas en la Unidad de Cuidados Intensivos. La asociación de las úlceras por presión con las variables se verificó a través de la prueba U de Mann-Whitney, prueba de chi-cuadrado, razón de verosimilitud y el test exacto de Fisher. Los factores de riesgo se identificaron mediante regresión logística múltiple. Resultados: De 324 pacientes, 46 (14.2%) desarrollaron úlceras por presión con mayor frecuencia en las regiones sacra y calcánea. Los factores de riesgo para la aparición de úlceras por presión fueron la edad, la duración de la hospitalización y la estancia hospitalaria antes de ingresar a la Unidad de Cuidados Intensivos. Discusión: La alta incidencia, la localización y el estadio de las úlceras por lesión observadas revelan la vulnerabilidad del paciente de la unidad de cuidados intensivos a este tipo de lesiones. Entre los riesgos de las úlceras por presión se encuentran factores relacionados con el paciente, la hospitalización y la gravedad de la enfermedad, y su combinación debe valorarse en la evaluación diaria del paciente crítico. Conclusión: La aparición de úlceras por presión en pacientes críticos es un fenómeno multifactorial, para la que el reconocimiento de factores de riesgo puede contribuir a una rápida adopción de medidas para su prevención Como citar este artículo: Campos, Michelle Mayumi Yoshimura de; Souza, Mariana Fernandes Cremasco de;  Whitaker, Iveth Yamaguchi.  Risco para lesão por pressão em pacientes de unidade de terapia intensiva. Revista Cuidarte. 2021;12(2):e1196. http://dx.doi.org/10.15649/cuidarte.1196    

Hospital-Acquired Pressure Injury Development Among Surgical Critical Care Patients Admitted With Community-Acquired Pressure Injury: A Retrospective Cohort Study

PURPOSE

Community-acquired pressure injuries (CAPIs) are present among approximately 3% to 8% of patients admitted to acute care hospitals. In the critical care population, little is known about hospital-acquired pressure injury (HAPI) development among patients with CAPIs because most studies exclude patients with CAPIs. The purpose of our study was to determine the incidence of HAPI development and the associated risk factors among surgical critical care patients with CAPIs.

DESIGN

Retrospective cohort study.

SUBJECTS AND SETTING

We used electronic health record data from adult critical care patients admitted to the surgical and cardiovascular surgical intensive care units (ICUs) at a level 1 trauma center and academic medical center between 2014 and 2018.

METHODS

Univariate analysis was used to compare patients with CAPIs who developed a HAPI and those who did not, as well as logistic regression analysis to identify independent risk factors for HAPIs among patients with CAPIs.

RESULTS

Among 5101 patients admitted to 2 surgical critical care units, 167 (3%) patients were admitted with CAPIs. Hospital-acquired pressure injuries were 4 times more common among patients with CAPIs compared to patients without CAPIs. Among the 167 patients with CAPIs, 47 patients (28%) went on to also develop a HAPI, whereas in the 4934 patients without CAPIs, 352 patients (7%) went on to develop a HAPI. Findings from the multivariate logistic regression analysis (n = 151) showed that decreased serum albumin (odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.25-0.85; P = .02) and excessively dry skin (OR = 2.6; 95% CI, 1.1-6.22; P = .03) were independent predictors of HAPI development among patients admitted with CAPIs.

CONCLUSIONS

Results from our study show that patients with CAPIs are at high risk for developing a HAPI, particularly among patients with decreased serum albumin or excessively dry skin. Patients with excessively dry skin may benefit from the application of skin moisturizers.

Risk Factors for Pressure Injury Development Among Critical Care Patients

Identification of the appropriate pressure injury (PI) risk factors is the first step in successful PI prevention. Measuring PI risk through formalized PI risk assessment is an essential component of any PI prevention program. Major PI risk factors identified in the empirical literature in the critical care population include age, diabetes, hypotension, mobility, prolonged intensive care unit admission, mechanical ventilation and vasopressor administration. Future risk assessment using sophisticated data analytics available in the electronic medical record may result in earlier, targeted PI prevention and will improve our understanding of risk factors that may contribute to unavoidable PIs.

Implementing a Pressure Injury Care Bundle in Chinese Intensive Care Units

Background

The incidence of pressure injury (PI) in intensive care units (ICUs) is high with a low compliance rate for PI prevention standard care. Although studies have confirmed that PIs are largely preventable, a PI care bundle based on the best evidence in Chinese ICUs is lacking.

Aim

The aims of this study are to assess the effectiveness of our PI care bundle-which is based on the best evidence and designed to prevent the development of ICU PIs-and to identify the changes in nurse compliance rates during the implementation process.

Methods

A quasi-experimental, pre- and post-intervention design was used. Implementation strategies included training, auditing during the use of the care bundle, and measuring outcome indicators in the ICU. The key elements of the care bundle were risk identification, skin assessment, patient repositioning, skin care, use of a pressure-reducing device, and nutrition. The number and stage of PIs were collected at three time points by unit staff. The implementation compliance rate was measured at two time points using a compliance checklist.

Results

Pressure injury rates were reduced significantly from 13.86% to 10.41%. The incidence of new hospital-acquired pressure injuries (HAPI) decreased by 29.5% within 6 months. The compliance rate of nurses increased significantly from 55.15% to 60.15% before and after the implementation of the care bundle (χ²=16.72, P=0.00); This result may be attributable to the implementation of care bundle training for nurses and the audit.

Conclusion

A standardized care bundle based on the best evidence is indicated to effectively reduce the incidence of PIs. The increase in compliance rate after the intervention may benefit from nurses training in the care bundle and the audit during the intervention.

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BACKGROUND

Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.

OBJECTIVES

The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.

METHODS

A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.

RESULTS

Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126).

CONCLUSIONS

We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

Using Pressure Mapping to Optimize Hospital-Acquired Pressure Injury Prevention Strategies in the Burn Intensive Care Unit

Although prior studies have demonstrated the utility of real-time pressure mapping devices in preventing pressure ulcers, there has been little investigation of their efficacy in burn intensive care unit (BICU) patients, who are at especially high risk for these hospital-acquired injuries. This study retrospectively reviewed clinical records of BICU patients to investigate the utility of pressure mapping data in determining the incidence, predictors, and associated costs of hospital-acquired pressure injuries (HAPIs). Of 122 patients, 57 (47%) were studied prior to implementation of pressure mapping and 65 (53%) were studied after implementation. The HAPI rate was 18% prior to implementation of pressure monitoring, which declined to 8% postimplementation (chi square: P = .10). HAPIs were less likely to be stage 3 or worse in the postimplementation cohort (P < .0001). On multivariable-adjusted regression accounting for known predictors of HAPIs in burn patients, having had at least 12 hours of sustained pressure loading in one area significantly increased odds of developing a pressure injury in that area (odds ratio 1.3, 95% CI 1.0-1.5, P = .04). Patients who developed HAPIs were significantly more likely to have had unsuccessful repositioning efforts in comparison to those who did not (P = .02). Finally, implementation of pressure mapping resulted in significant cost savings-$6750 (standard deviation: $1008) for HAPI-related care prior to implementation, vs $3800 (standard deviation: $923) after implementation, P = .008. In conclusion, the use of real-time pressure mapping decreased the morbidity and costs associated with HAPIs in BICU patients.

Effectiveness of skin cleanser and protectant regimen on incontinence-associated dermatitis outcomes in acute care patients: A cluster randomised trial

Skin cleansers and protectants protect skin from incontinent matter to reduce the risk of incontinence-associated dermatitis (IAD), but their effectiveness treating established IAD in the tropics is unknown. We conducted an open-label cluster randomised trial to compare the effectiveness of a combined regimen of (1) specialised skin cleansers with disposable body wipes and (2) either an acrylic terpolymer (T1) or zinc oxide (T2) skin protectant against disposable body wipes and zinc oxide protectant (control) in promoting IAD healing and reducing the risk of deterioration. Eighty-four patients were recruited in a tertiary hospital in Singapore between April 2019 and January 2020 (T1: n = 23; T2: n = 37; Control: n = 24). Although not statistically significant, patients treated with T1 and T2 were 1.5 times as likely to experience IAD healing within seven days compared with the control (P = .66). Healing was more pronounced in participants with skin loss treated with T1 or T2. No treatment was superior in preventing IAD deterioration, the prevalence of which remained small (8%-14%). While skin cleaning and protectants reduced the overall risk of skin deterioration, the addition of skin cleansers enhanced IAD healing within a short period, an important consideration for future research examining IAD treatment in acute care.

Facilitating Factors in the Proper Identification of Acute Skin Failure: A Systematic Review

BACKGROUND

Acute skin failure is a significant medical finding for both the critical care patient and the hospital. Proper identification is key to prevention and treatment, but diagnosis of acute skin failure in critical care patients is often missed. This diagnostic oversight may be due to a lack of knowledge about acute skin failure and its presentation.

OBJECTIVE

To investigate the literature for facilitating factors that would ease the identification of acute skin failure for clinicians.

METHODS

The research team conducted a systematic literature review via PubMed, CINAHL, and Academic Search Ultimate to collect data about acute skin failure and how it might be identified.

RESULTS

Ten common facilitation themes around acute skin failure and its identification were found in the literature. In total, 110 examples of facilitating factors were identified.

CONCLUSIONS

There is little factual information available regarding the identification of acute skin failure, and the literature is lacking in this area overall. Acute skin failure may develop in the body in a number of ways, and understanding commonalities that occur in patients who experience acute skin failure and applying that information to patients in the future may assist identification.

Predicting pressure injury using nursing assessment phenotypes and machine learning methods

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pressure Injuries in Critical Care Patients: A Conceptual Schema

GENERAL PURPOSE

To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence pressure injury (PI) development in the critical care population.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Choose a static intrinsic factor that increases the risk for the development of PI. 2. List several dynamic intrinsic risk factors for developing a PI. 3. Identify dynamic extrinsic risk factors that may predispose a patient to developing a PI. 4. Explain the pathophysiology of PI development.

Effect of Hospital Linens on Unit-Acquired Pressure Injuries for Adults in Medical ICUs: A Cluster Randomized Controlled Trial

Researchers have shown in laboratory studies that different types of fabrics were associated with changes in skin moisture, friction, shear, and temperature that may predispose patients to pressure injury. There was an association between type of fiber used in hospital linens and pressure injury development in previous clinical studies. We examined if bed linens made from a newly developed synthetic fiber fabric affected occurrence rate, time to development, and severity of unit-acquired pressure injury in critically ill adult inpatients.

DESIGN

Cluster randomized controlled trial.

SETTING

Five adult medical ICUs within one quaternary care center in the Midwest United States.

PATIENTS

Patients were assigned to a unit based on bed availability. In total, there were 3,332 patients in the study.

INTERVENTIONS

Participating medical ICUs were randomly assigned to cotton fiber or synthetic fiber linens for the first 6 months of the study period, and assignment reversed after a 14-day washout period for the final 6 months.

MEASUREMENTS AND MAIN RESULTS

Unit-acquired pressure injury occurrence rate, time to first unit-acquired pressure injury, and severity were evaluated using generalized mixed effect models with patient as a random effect, and a marginal Cox proportional hazards model with repeated admissions from the same patient accounted for by use of a sandwich estimator of the variance. There were 1,706 patients on cotton fiber linens and 1,626 patients on synthetic fiber linens. Groups were similar on demographics except race and admitting diagnosis groupings. Occurrence rate (p = 0.99), time to development (p = 0.99), and maximum severity of unit-acquired pressure (p = 0.86) were similar between groups before and after controlling for race and admitting diagnosis groupings.

CONCLUSIONS

Linen type did not affect unit-acquired pressure injury occurrence rate, severity, or timing. Standard unit-acquired pressure injury prevention efforts may be more cost-effective than investment in synthetic fiber linens.

Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report

ABSTRACT

Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

Selected Biochemical Blood Parameters and a Risk of Pressure Ulcers in Patients Receiving Treatment in Intensive Care Units

Background and Objectives: This study aimed to assess the level of selected biochemical parameters in venous blood and their potential effects on the development of pressure ulcers in patients treated in intensive care settings. Materials and Methods: Fifty patients hospitalised in an intensive care unit (ICU) were enrolled for the study. The methods used included controlled observation, literature review and medical record analysis. The observation protocol applied in the study consisted of two parts comprising the basic information, sociodemographic data, results of laboratory tests (CRP, PCT, albumin, protein and haemoglobin concentrations) as well as the Braden Scale for Predicting Pressure Ulcer Risk. Results: The subjects presented moderate to high risk of pressure ulcers, reflected by the mean score of 8.18 ± 1.3 points, with minimum and maximum scores of 6 and 12 points, respectively. Normal albumin level was identified in only five subjects (10.0%) while 45 subjects (90.0%) were found with results below the norm. A statistical relationship was observed between such variables as albumin concentration (p < 0.01) and total protein level (p = 0.007). The findings show a strong correlation between the score in the Braden Scale and the level of albumins (R = 0.55). Conclusions: In our study, lower concentrations of albumins and total proteins correspond to a greater risk of pressure ulcers.

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

PURPOSE

Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients.

METHODS

International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis.

RESULTS

Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3).

CONCLUSION

Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.

Incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care: A systematic review and meta-analysis

BACKGROUND

Pressure injury is recognised as an adverse event occurring in healthcare settings. Patients in intensive care are at high risk of developing a pressure injury. Cardiac patients are also among those at higher risk.

OBJECTIVES

To systematically assess the incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care.

DESIGN

Systematic review and meta-analysis of incidence and prevalence REVIEW METHODS: Articles published in English between 2009 and 2018, reporting pressure injury as a primary outcome were selected based on inclusion criteria. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. A random effects meta-analysis was conducted. Sub-group meta-analyses were conducted to investigate potential causes of heterogeneity.

RESULTS

Fifteen studies met the criteria for inclusion in the systematic review, of which 14 were incidence studies. Heterogeneity was significant and there was large observed variance between studies. The 95% confidence interval of cumulative incidence across all 14 studies, with an overall sample size of 6371, was 9.8-25.6%. In 11 studies that included all-stage pressure injury the 95% confidence interval was 8.3-28.3%. In seven studies in which Stage 1 pressure injury was excluded, the 95% confidence interval was 5.8-22.7%. In the single prevalence study included, which excluded Stage 1 pressure injury, prevalence was 8.8%.

CONCLUSIONS

The incidence of pressure injury in cardiac intensive care patients was similar to that found in general intensive care patients. However, our results suggest that the incidence may be significantly higher in cardiac surgical patients admitted to intensive care. There were significant differences across the various studies in the ways in which data were collected and reported. Further well-designed studies are required to better understand incidence in this population, using standardised methods of data collection and reporting.