Evidence-based prevention of pressure ulcers in the intensive care unit

Turning frequency in adult bedridden patients to prevent hospital-acquired pressure ulcer: A scoping review

The aim of this study was to identify current research on turning frequencies of adult bed-bound patients and inform future turning practices for hospitals based on evidence-based practice. We undertook a scoping review framework that provided a transparent and systematic methodology using 8 electronic databases (CINAHL, PubMed, Cochrane Library, ScienceDirect, PsycINFO, Scopus, ProQuest, and Web of Science) to identify articles published from 2000 to 2016. Articles were included if they focused on the prevention of hospital-acquired pressure ulcers related to the frequency of turning or repositioning of bed-bound patients. Literature search and data extraction were performed independently by 3 authors. The study followed the PRISMA guidelines. In total, 911 articles were identified, of which 10 were eligible. Of the eligible articles, 8 studies could not reach a conclusion on the effective frequency of turning and duration for repositioning patients to prevent the development of pressure ulcers. Only 2 studies found significant differences among the intervention and control groups. Results regarding turning and repositioning schedules are inconclusive; however, the topic needs further exploration to improve the outdated guidelines surrounding pressure ulcer prevention. This may, in turn, make the work of nurses more efficient and make treatment cost-effective for both the patients and the hospitals.

Reducing pressure ulcers in patients with prolonged acute mechanical ventilation: a quasi-experimental study

Objective:

To determine the effectiveness of a quality management program in reducing the incidence and severity of pressure ulcers in critical care patients.

Methods:

This was a quasi-experimental, before-and-after study that was conducted in a medical-surgical intensive care unit. Consecutive patients who had received mechanical ventilation for ≥ 96 hours were included. A "Process Improvement" team designed a multifaceted interventional process that consisted of an educational session, a pressure ulcer checklist, a smartphone application for lesion monitoring and decision-making, and a "family prevention bundle".

Results:

Fifty-five patients were included in Pre-I group, and 69 were included in the Post-I group, and the incidence of pressure ulcers in these groups was 41 (75%) and 37 (54%), respectively. The median time for pressure ulcers to develop was 4.5 [4 - 5] days in the Pre-I group and 9 [6 - 20] days in the Post-I group after admission for each period. The incidence of advanced-grade pressure ulcers was 27 (49%) in the Pre-I group and 7 (10%) in the Post-I group, and finally, the presence of pressure ulcers at discharge was 38 (69%) and 18 (26%), respectively (p < 0.05 for all comparisons). Family participation totaled 9% in the Pre-I group and increased to 57% in the Post-I group (p < 0.05). A logistic regression model was used to analyze the predictors of advanced-grade pressure ulcers. The duration of mechanical ventilation and the presence of organ failure were positively associated with the development of pressure ulcers, while the multifaceted intervention program acted as a protective factor.

Conclusion:

A quality program based on both a smartphone application and family participation can reduce the incidence and severity of pressure ulcers in patients on prolonged acute mechanical ventilation.

The ABCDs of Managing Morbidly Obese Patients in Intensive Care Units

More than one-third of the US adult population and 17% of the youth are now obese, and obesity is associated with more than $147 billion a year in health care costs. Critical care nurses should understand the physiological differences and practice guidelines for patients with a body mass index greater than 30. The ABCD approach encompasses key clinical concepts in the management of critically ill obese and morbidly obese patients, including management of airways and breathing, minimizing nurses' back and other injuries, increasing awareness of bias, circulation problems, risks of decubitus ulcers and other skin breakdown, differences in drug calculations and metabolism, limitations in diagnostic equipment and imaging, diet and nutritional recommendations, and concerns with durable medical equipment.

Management of Acute Respiratory Failure in the Patient with Sepsis or Septic Shock

Sepsis and septic shock are each commonly accompanied by acute respiratory failure and the need for invasive as well as non-invasive ventilation throughout a patient's intensive care unit course. We explore the underpinnings of acute respiratory failure of pulmonary as well as non-pulmonary origin in the context of invasive and non-invasive management approaches. Both pharmacologic and non-pharmacologic adjuncts to ventilatory and oxygenation support are highlighted as well. Finally, rescue modalities are positioned within the intensivist's armamentarium for global care of support of the critically ill or injured patient with sepsis or septic shock.

Impact of the introduction of an endotracheal tube attachment device on the incidence and severity of oral pressure injuries in the intensive care unit: a retrospective observational study

BACKGROUND

Endotracheal tube (ETT) fasteners such as the AnchorFast™ claim to assist with the prevention of oral pressure injuries in intubated patients, however evidence to support their clinical efficacy is limited. This retrospective observational study aimed to investigate the impact of the introduction of the AnchorFast™ device on the incidence of oral pressure injuries in mechanically ventilated patients.

METHODS

Data was collected from patient case notes and clinical incident reports for October 2010 to June 2013 (pre-AnchorFast) and July 2013 to March 2016 (post-AnchorFast). Incidence and location of oral pressure injuries associated with securing device, and compliance with institutional policies related to reducing oral pressure injuries were recorded.

RESULTS

Incidence of oral pressure injuries increased from 1.53/100 intubated patients in the pre-AnchorFast period to 3.73/100 intubated patients in the post-AnchorFast period (IRR = 2.43, 95%CI = 1.35-4.38; p = 0.003). Across both study periods, patients with an ETT secured using AnchorFast™ had significantly increased risk of oral pressure injuries (IRR = 2.03, 95%CI = 1.17-3.51; p = 0.02). There was also a significant difference in location of pressure injuries sustained with ETTs secured using cloth tapes (53.6% in corner of the mouth) vs. AnchorFast™ (75% on the lips) (p = 0.008). Among patients with oral pressure injuries, compliance with institutional policies relating to the prevention of pressure injuries was significantly greater after the introduction of the AnchorFast™ (9.1% vs 64.5%, p = 0.004).

CONCLUSIONS

The incidence of oral pressure injuries increased significantly following the introduction of the AnchorFast™ device. Further research is required to establish the reasons for this observed increase to and identify ways to reduce the risk of pressure injuries with ETT securement devices.

[Impact of interventions in the pressure ulcer rate]

OBJECTIVE

To evaluate the impact of a risk management program for prevention of pressure ulcers (PUs) in an adult Intensive Care Unit (ICU).

MATERIAL AND METHODS

A quantitative, prospective study performed with a «before and after» evaluation, and designed in three stages: 1) PU incidence study; 2) Intervention by implementing a risk management program, and 3) Assessment of the impact.

RESULTS

Adherence to the preventive measures showed a significant increase (11.7%) between the first month of the program and the final month (58.5%) of the assessment. Initial PU rate was 20.9, with a decrease in the rate to 14.0 per 1000 bed occupancy days (P<.05) after the risk management program.

CONCLUSIONS

The data show that the risk management program, using prevention measures, was effective in reducing the rate of PU in the period under study by more than 33%.

Pressure ulcers in critically ill patients - Preventable by non-sedation? A substudy of the NONSEDA-trial

OBJECTIVE

Pressure ulcers still pose a significant clinical challenge to critically ill patients. This study is a substudy of the multicenter NONSEDA-trial, where critically ill patients were randomised to sedation or non-sedation during mechanical ventilation. The objective of this substudy was to assess if non-sedation affected the occurrence of pressure ulcers.

DESIGN

Retrospective assessment of data from a single NONSEDA-trial site.

SETTING

Mixed intensive care unit.

OUTCOME MEASURES

The occurrence of pressure ulcers, described by grade and location.

RESULTS

205 patients were included. Patients with pressure ulcers in the two groups were comparable with regards to baseline data. There were 44 ulcers in 32 patients in the sedated group and 31 ulcers in 25 patients in the non-sedated group (p=0.08). 64% of the ulcers in sedated patients were located on sacrum and heels, whereas 68% of the ulcers in non-sedated patients were related to equipment (p=0.03).

CONCLUSIONS

Non-sedation did not significantly reduce the number of pressure ulcers. Non-sedation significantly affected the location of ulcers: non-sedated patients mainly had ulcers related to equipment, whereas sedated patients mainly had ulcers on the sacrum and heels.

Comparison of awareness of patient parameters between two groups of caregivers in intensive care unit

Aim of the Study:

Materials and Methods:

Results:

Conclusions:

Nursing Management of Adults with Severe Traumatic Brain Injury: A Narrative Review

Effective nursing management strategies for adults with severe traumatic brain injury (STBI) are still a remarkable issue and a difficult task for neurologists, neurosurgeons, and neuronurses. A list of justified indications and scientific rationale for nursing management of these patients are continuously evolving. The objectives of the study are to analyze the pertinently available research and clinical studies that demonstrate the nursing management strategies for adults with STBI and to synthesize the available evidence based on the review. A comprehensive literature search was made in following databases such as Google Scholar, Cochrane, J-Gate, ProQuest, and ScienceDirect for retrieving the related studies. In the included studies, data were extracted and evaluated according to the objective. Narrative analysis was adopted to write this review. Patients with STBI have poor prognosis and require quality care for maximizing patients' survival. With a thorough knowledge and discernment of care of such patients, nurses can improve these patients' neurological outcomes.

Pressure ulcer dressings in critical patients: a cost analysis

OBJECTIVE

To assess the direct cost of dressings in pressure ulcer treatment.

METHOD

This was a descriptive observational study conducted at an intensive care unit in the Northeast region of Brazil, between November and December 2015. Data were gathered using the Pressure Ulcer Scale for Healing and a form to characterize and assess costs. Values in Brazilian reais (BRL) were converted into U.S. dollars at the exchange rate of USD 0.26/BRL. Univariate and bivariate analyses were conducted.

RESULTS

The sample consisted of 15 patients with at least stage 2 ulcers. There was a significant reduction in costs with dressing materials between the initial and final assessments (p=0.002), with a mean of USD 11.9 (±7.4). The most common topical treatments used were essential fatty acids and papain.

CONCLUSION

Cost reduction was proportional to the stage of pressure ulcer. The role of nurses in creating evidence-based care plans is crucial to improve care management.

OBJETIVO

Avaliar o custo direto com curativos no tratamento de lesões por pressão.

MÉTODO

Estudo observacional descritivo, realizado em Unidade de Terapia Intensiva do nordeste do Brasil, de novembro a dezembro de 2015. Foi aplicada a Pressure Ulcer Scale for Healing e formulário para caracterização e avaliação de custos. Os valores da moeda brasileira (R$) foram convertidos para a moeda norte-americana (US$) à taxa de US$0,26/R$. Foram realizadas análises univariadas e bivariadas.

RESULTADOS

Compuseram a amostra 15 pacientes com lesões, no mínimo, estágio 2. Houve redução significativa dos custos com materiais de curativos entre as avaliações inicial e final (p=0,002), com média de US$11,9 (±7,4). As terapias tópicas mais frequentes foram ácidos graxos essenciais e papaína.

CONCLUSÃO

Verificou-se redução de custos proporcional aos estágios das lesões. Enfatiza-se o papel do enfermeiro na elaboração de planos de cuidados baseados em evidências para melhor gerenciamento do cuidado.

OBJETIVO

Evaluar el costo directo de curativos para el tratamiento de lesiones por presión.

MÉTODO

Estudio observacional descriptivo en la Unidad de Cuidados Intensivos del noreste de Brasil, de noviembre a diciembre del año 2015. Se aplicó la Pressure Ulcer Scale for Healing y formulario para la caracterización y evaluación de los costos. Los valores de la moneda brasileña (Reales- R$) se convirtieron al dólar estadounidense (US$) a razón de $0.26/R$. Se realizaron análisis univariados y bivariados.

RESULTADOS

La muestra consistió en 15 pacientes con lesiones al menos en Etapa 2. Hubo una reducción significativa en el costo de los materiales de curación entre las evaluaciones inicial y final (p=0,002), con un promedio de US$11.9 (±7.4). Los tratamientos tópicos más comunes son los ácidos grasos esenciales y papaína.

CONCLUSIÓN

Se verificó una reducción de los costos proporcional a las etapas de las lesiones. Se hace hincapié en el papel de los enfermeros en el desarrollo de planes de cuidados basados en la evidencia, para una mejor gestión de la atención.

Translating Pressure Ulcer Prevention Into Intensive Care Nursing Practice: Overlaying a Care Bundle Approach With a Model for Research Implementation

This article reports on the development and implementation process used to integrate a care bundle approach (a pressure ulcer [PU] prevention bundle to improve patients' skin integrity in intensive care) and the Ottawa Model of Research Use (OMRU). The PU prevention care bundle demonstrated significant reduction in PU incidence, with the OMRU model providing a consolidated framework for the implementation of bundled evidence in an effective and consistent manner into daily clinical nursing practice.

Inter-rater reliability of the Reaper Oral Mucosa Pressure Injury Scale (ROMPIS): A novel scale for the assessment of the severity of pressure injuries to the mouth and oral mucosa

BACKGROUND

Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth.

OBJECTIVES

This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa.

METHODS

The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha (α).

RESULTS

Among ICU nurses (n=52), IRR of the ROMPIS was α=0.307; improving to α=0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care (n=8), IRR was α=0.306; or α=0.443 excluding responses indicating that wounds were unstageable.

CONCLUSIONS

An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.

Prevention and treatment of skin lesions associated with non-invasive mechanical ventilation. Recommendations of experts

INTRODUCTION

In the last two decades, non-invasive mechanical ventilation (NIV) has been consolidated as an initial strategy for the management of respiratory failure in critical adult and paediatric patients.

OBJECTIVES

To identify risk factors and preventive strategies to reduce the incidence of skin lesions associated with clinical devices (LESADIC) related to NIV, as well as the most effective treatment for injuries that cannot be avoided.

METHODOLOGY

Review in the MEDLINE, CINAHL and Cochrane databases of studies published in the last 10years to reach consensus through an expert panel.

RESULTS

Knowledge about how to measure correct mask size and protection of the skin with foam or hydrocolloids dressings are factors related to the incidence of LESADIC, as it conditions the degree of pressure-friction and shear that the interface exerts on the skin. The interface that causes fewer LESADIC and is better tolerated is the face mask. When there are injuries, the first thing is to remove the interface that causes pressure on damaged skin, recommending a Helmet^® hood as an alternative, treating the infection, managing the exudate and stimulating perilesional skin.

CONCLUSIONS

The mask of choice is the facial, always using foam or hydrocolloid dressings on the nasal bridge. Evaluate the condition of the skin under the interface and harness every 4hours (recommended) and 11hours (maximum). Evaluate the rotation strategy of the interface at 24hours if the NIV is still needed on an ongoing basis.

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit

BACKGROUND

In critically ill patients, prevention of pressure ulcers is a challenge because of the high risk for multiple comorbid conditions, immobility, hemodynamic instability, and increased use of medical devices.

OBJECTIVES

To compare the difference in incidence rates of hospital-acquired pressure ulcers (HAPUs) in critically ill patients between those treated with usual preventive care and a 5-layered soft silicone foam dressing versus a control group receiving usual care. Secondary goals were to examine risk factors for HAPUs in critically ill patients and to explicate cost savings related to prevention of pressure ulcers.

METHODS

A prospective, randomized controlled trial in the intensive care units at a 569-bed, level II trauma hospital. All 366 participants received standard pressure ulcer prevention; 184 were randomized to have a 5-layered soft silicone foam dressing applied to the sacrum (intervention group) and 182 to receive usual care (control group).

RESULTS

The incidence rate of HAPUs was significantly less in patients treated with the foam dressing than in the control group (0.7% vs 5.9%, P = .01). Time to injury survival analysis (Cox proportional hazard models) revealed the intervention group had 88% reduced risk of HAPU development (hazard ratio, 0.12 [95% CI, 0.02-0.98], P = .048).

CONCLUSION

Use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant benefit in reducing the incidence rate and severity of HAPUs in intensive care patients. This novel, cost-effective method can reduce HAPU incidence in critically ill patients.

Pressure Ulcers: Developing Clinical Indicators in Evidence-based Practice. A Prospective Study

Aims and objectives:

It is widely recognized that Intensive Care Unit (ICU) patients have a greater likelihood of developing pressure ulcers in comparison to hospital or home care patients. Accordingly, this study aimed to evaluate whether specific clinical characteristics could be used as clinical indicators towards pressure ulcers prevention.

Method:

We monitored 210 hospitalized ICU patients during a 12-month period. Pressure ulcers were assessed following the current guidelines. Clinical characteristics such as gender, age, hospitalized days, hemodialysis treatment, hematocrit, and serum albumin levels were considered as the most common predictors for pressure ulcers development. The significance of associations was controlled using multiple logistic regression after adjusting for clinical characteristics and was presented as adjusted odds ratio (AOR).

Results:

The prevalence of pressure ulcers was 24.3%. Logistic regression revealed that patients with increased age AOR=1.04; (CI: 1.01-1.07) and last-long hospitalization AOR=1.17; (CI: 1.11-1.23) were significantly more likely to present pressure ulcers compared to the younger ones and patients with less length of stay, respectively. We also found that patients under hemodialysis treatment were more likely to present pressure ulcers AOR=4.09; (CI: 1.12-14.98) compared to patients that did not underwent hemodialysis and the risk of pressure ulcers development was decreased by 9% for every single unit of hematocrit value increase AOR=0.91; (CI: 0.82-0.99).

Conclusion:

Our data analysis confirms that the clinical characteristics that were studied are independently associated with pressure ulcers development, and therefore, it is a crucial incentive to consider that these specific clinical characteristics are important indicators in the evidence-based practice.

Evaluating optimal patient-turning procedures for reducing hospital-acquired pressure ulcers (LS-HAPU): study protocol for a randomized controlled trial

Background

Pressure ulcers are insidious complications that affect approximately 2.5 million patients and account for approximately US$11 billion in annual health care spending each year. To date we are unaware of any study that has used a wearable patient sensor to quantify patient movement and positioning in an effort to assess whether adherence to optimal patient turning results in a reduction in pressure ulcer occurrence.

Methods/design

This study is a single-site, open-label, two-arm, randomized controlled trial that will enroll 1812 patients from two intensive care units. All subjects will be randomly assigned, with the aid of a computer-generated schedule, to either a standard care group (control) or an optimal pressure ulcer-preventative care group (treatment). Optimal pressure ulcer prevention is defined as regular turning every 2 h with at least 15 min of tissue decompression. All subjects will receive a wearable patient sensor (Leaf Healthcare, Inc., Pleasanton, CA, USA) that will detect patient movement and positioning. This information is relayed through a proprietary mesh network to a central server for display on a user-interface to assist with nursing care. This information is used to guide preventative care practices for those within the treatment group. Patients will be monitored throughout their admission in the intensive care unit.

Discussion

We plan to conduct a randomized control trial, which to our knowledge is the first of its kind to use a wearable patient sensor to quantify and establish optimal preventative care practices, in an attempt to determine whether this is effective in reducing hospital-acquired pressure ulcers.

Trial registration

ClinicalTrials.gov, NCT02533726.

Avaliação de custo-efetividade de dois tipos de curativos para prevenção de úlcera por pressão

Resumo Objetivo : Analisar a relação custo-efetividade de dois tipos de curativos para a prevenção de úlcera por pressão na região sacral. Métodos : Pesquisa de análise secundária, comparativa, que incluiu 25 pacientes dos quais dez utilizaram a cobertura hidrocoloide e 15 o filme transparente, para prevenção de úlcera por pressão na região sacral. Foram contabilizados custos de aquisição com cada tipo de cobertura; verificados desfechos intermediário e final; e foi estimada a relação custo-efetividade. Resultados : A relação custo-efetividade do hidrocoloide para o desfecho intermediário foi de R$174,68 enquanto do filme transparente foi de R$45,74. Para o desfecho final, essa relação foi de respectivamente R$272,00 e R$28,97. Conclusão : O filme transparente foi mais custo-efetivo do que o hidrocoloide na prevenção de úlcera por pressão sacral.

Reducing hospital acquired pressure ulcers in intensive care

Pressure ulcers are a definite problem in our health care system and are growing in numbers. Unfortunately, it is usually the most weak and vulnerable of our culture that faces these complications, causing the patient and their families discomfort, anguish, and economic hardship due to their expensive treatment. Data collected by the tissue viability department showed high incidence of hospital acquire pressure ulcers in the intensive care unit in March 2013. An action plan was initiated and implemented by the tissue viability team, senior nursing management, pressure ulcer prevention (PUP) team and respiratory therapists (RT's) within the ICU. Our objective was to reduce hospital acquired pressure ulcers in the intensive care unit using the plan, do, check, act quality improvement process.

A critical care network pressure ulcer prevention quality improvement project

BACKGROUND

Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost.

AIMS

This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards.

METHODS

The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document.

RESULTS

The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions.

CONCLUSION

The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network.

RELEVANCE TO CLINICAL PRACTICE

A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention.

Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care patients on mechanical ventilation

RATIONALE, AIMS AND OBJECTIVES

Pressure ulcers (PUs) are a common and serious complication in critically ill patients. The aim of this study was to evaluate the relationship between the development of a PU and hospital mortality in patients requiring mechanical ventilation (MV) in an intensive care unit (ICU).

METHODS

A prospective cohort study was performed over two years in patients requiring MV for ≥ 24 hours in a medical-surgical ICU. Primary outcome measure was hospital mortality and main independent variable was the development of a PU grade ≥ II. Hazard ratios (HRs) were calculated using a Cox model with time-dependent covariates.

RESULTS

Out of 563 patients in the study, 110 (19.5%) developed a PU. Overall hospital mortality was 48.7%. In the adjusted multivariate model, PU onset was a significant independent predictor of mortality (adjusted HR, 1.28; 95% confidence interval, 1.003-1.65; P = 0.047). The model also included the Acute Physiology and Chronic Health Evaluation II score, total Sequential Organ Failure Assessment on day 3, hepatic cirrhosis and medical admission.

CONCLUSION

Within the limitations of a single-centre approach, PU development appears to be associated with an increase in mortality among patients requiring MV for 24 hours or longer.