Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis

Role of microRNAs in Pressure Ulcer Immune Response, Pathogenesis, and Treatment

Pressure ulcers are preventable, yet highly prevalent, chronic wounds that have significant patient morbidity and high healthcare costs. Like other chronic wounds, they are characterized by impaired wound healing due to dysregulated immune processes. This review will highlight key biochemical pathways in the pathogenesis of pressure injury and how this signaling leads to impaired wound healing. This review is the first to comprehensively describe the current literature on microRNA (miRNA, miR) regulation of pressure ulcer pathophysiology.

Prevalence, incidence, length of stay and cost of healthcare-acquired pressure ulcers in pediatric populations: A systematic review and meta-analysis

BACKGROUND

Pressure ulcers are a major problem for national healthcare systems since they frequently occur in hospitalized patients, negatively affecting patients' quality of life and extending duration of hospitalization.

OBJECTIVE

To systematically review the available evidence regarding the incidence, prevalence, attributable length of stay and cost of hospital-acquired pressure ulcers in pediatric populations.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search (March 15, 2020) was conducted in PubMed, Scopus, and ProQuest databases. Cross-sectional and cohort studies of neonates and children aged <21 years old were eligible for inclusion when full text was available in English and data for at least one of the following criteria was provided: incidence, prevalence, attributable length of stay or healthcare cost due to hospital-acquired pressure ulcers. Study quality was evaluated using the Joanna Briggs Institute Critical Appraisal Tools. Random effects models were used to synthesize data. Heterogeneity and publication bias were evaluated.

RESULTS

From the 1055 studies appeared in literature search, 21 studies were included in the systematic review and 19 were included in the meta-analysis. The overall prevalence ranged from 0.47% to 31.2% and cumulative incidence ranged from 3.7% to 27%. The pooled prevalence was estimated at 7.0% (95% confidence interval (CI): 4.3%-10.4%) and the pooled cumulative incidence at 14.9% (95% CI: 7.7%-23.9%). The pooled prevalence among neonates was 27.0% (95% CI: 22.1%-33.1%) among children aged less than 1 year old was 19.2% (95% CI: 9.4%-31.3%) and among children older than 1 year was 12.3% (95% CI: 2.3%-27.9%). The cumulative incidence of hospital-acquired pressure ulcers in neonates was 9.8% (95% CI: 2.9%-19.8%) and in children aged <1 year old was 11.3% (95% CI: 4.4%-20.7%), while no data was available to estimate this figure for children older than 1 year. The attributable length of stay ranged from 0.9 to 14.1 days and the attributable cost ranged from $894.69 to $98,730.24 (United States dollars; value of a dollar in 2020) per patient with hospital-acquired pressure ulcers.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The results of this meta-analysis indicate that hospital-acquired pressure ulcers occur frequently in pediatric populations with a great variation across different age groups. Moreover, although limited data are available, it seems that hospital-acquired pressure ulcers have significant economic implications for the healthcare systems since they prolong patients' hospitalization stay; these findings further highlight the need for implementation of patient-based prevention strategies.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Not registered Tweetable abstract: Hospital-acquired pressure ulcers occur frequently in pediatric populations, prolonging their hospitalization and increasing the healthcare cost.

Relationship Between Prescription and Documentation of Pressure Injury Prevention Interventions and Their Implementation: An Exploratory, Descriptive Study

BACKGROUND

Formal assessment by nurses of a patient's pressure injury (PI) risk level is often highlighted as being key to PI prevention. However, if no action is taken to address the determined risk (i.e., if appropriate preventative interventions are not implemented), the patient remains vulnerable to PI development, and the assessment process is rendered pointless.

AIM

To explore the relationship between the prescription (planning) and implementation of PI preventative interventions by nurses following formal risk assessment.

METHODS

Using an exploratory, descriptive design, the charts and bedside areas of 200 adult patients admitted across four hospital wards were examined. Data collected included PI risk level, documented prescribed preventative interventions, and interventions for which there was evidence of implementation.

RESULTS

Of the final sample (n = 187), 66.8% of cases were categorized as being "at-risk" or above. As the risk category of patients increased, proportionately more patients in each category were prescribed each intervention. However, in most cases, significantly fewer interventions were actually implemented than were prescribed, except for several interventions that were implemented in more cases than were prescribed. There were 14 cases, including four at-risk and three high-risk patients, in which no preventative interventions were prescribed, while 88.7% of not at-risk patients had (unnecessary) preventative interventions prescribed.

DISCUSSION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. The results indicate a significant mismatch between these two steps of PI prevention.

LINKING EVIDENCE TO ACTION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. A significant mismatch between these two steps of PI prevention was evident. Following patient risk assessment, there should be a greater focus on appropriate preventative intervention prescription (planning) with regular review and audit to help ensure that interventions are implemented as prescribed. Improved implementation of preventative interventions should, in turn, help to reduce hospital-acquired pressure injuries.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background

Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs).

Objectives

To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone.

Methods

This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At‐risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) – pooled as the treatment group – and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites.

Results

In the intention‐to‐treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41–0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35–0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34–1·68, P = 0·49).

Conclusions

Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at‐risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

What is already known about this topic?

The incidence of hospital‐acquired pressure ulcers (PUs) remains high despite the implementation of best‐practice recommendations.

The concept of using silicone foam dressings as an additional prophylactic strategy in PU prevention has been investigated in previous studies but with some limitations.

Most RCTs were monocentric studies, restricted to either critically ill or acute care patients and did not observe more than two anatomical at‐risk skin sites, which limited the generalizability of the findings.

What does this study add?

This large pragmatic RCT suggests that it is beneficial to use silicone adhesive multilayer foam dressings on the sacrum, in addition to standard of care, to help prevent hospital‐acquired PUs.

Clinical decision making for heel dressings should be based on the clinical effectiveness of the intervention weighed against the potential risk of falling.

Linked Comment: F. Coyer. Br J Dermatol 2021; 185:4–5.

Attitudes of Spanish Nurses towards Pressure Injury Prevention and Psychometric Characteristics of the Spanish Version of the APuP Instrument

The prevention of pressure injuries in hospitalised patients is a critical point of care related to patient safety. Nurses play a key role in pressure injury (PI) prevention, making it important to assess not only their knowledge but also their attitude towards prevention. The main purpose of this study was to translate into Spanish and evaluate the psychometric properties of the Attitude towards Pressure ulcer Prevention instrument (APuP); a secondary aim was to explore the associations of attitude with other factors. A Spanish version was developed through a translation and back-translation procedure. The validation study was conducted on a sample of 438 nursing professionals from four public hospitals in Spain. The analysis includes internal consistency, confirmatory factorial analysis, and construct validity in known groups. The 12-item Spanish version of the APuP fit well in the 5-factor model, with a Cronbach's alpha of 0.7. The mean APuP score was 39.98, which means a positive attitude. Registered nurses have a slightly better attitude than Assistant nurses. A moderate correlation (R = 0.32) between knowledge and attitude for the prevention of PI was found. As concluded, the Spanish version of the APuP questionnaire is a valid, reliable and useful tool to measure the attitude toward PI prevention in Spanish-speaking contexts. This version has 12 items grouped into 5 factors, and its psychometric properties are similar to those of the original instrument.

Prevalence of pressure ulcers in africa: A systematic review and meta-analysis

BACKGROUND

A recent global review of pressure ulcers contained no studies from Africa.

OBJECTIVE

To identify the prevalence and incidence of pressure ulcers in Africa.

DATA SOURCES

Bibliographic databases, African specific databases, grey literature.

STUDY ELIGIBILITY CRITERIA

Studies with prevalence or incidence data of pressure ulcers from Africa since the year 2000.

PARTICIPANTS

Any age, including children, in any setting, specifically including hospital patients from any clinical area but not restricted to hospital settings.

STUDY APPRAISAL AND SYNTHESIS METHODS

Hoy score for bias, Joanna Briggs Institute Critical Appraisal Instrument.

METHOD

We followed the PRISMA guideline for systematic reviews. We searched Embase, Medline, Scopus, CINHAL, Google Scholar, specialist African databases and grey literature for studies reporting incidence or prevalence data.

RESULTS

Nineteen studies met the inclusion criteria and were included in the study. Point prevalence rates varied from 3.4% to 18.6% for medical/surgical and other general hospital units with a pooled prevalence of 11%, for grades II-IV 5%. For spinal injury units the pooled prevalence was 44%.

LIMITATIONS

restricted to English, French and Arabic.

CONCLUSION

Prevalence of pressure ulcers in Africa reported here is similar to figures from a recent review of prevalence in Europe and two recent global reviews of hospitalised patients. Prevalence of pressure ulcers in spinal cord injury patients is similar to figures from a review of developing countries. The reporting of prevalence is lacking in detail in some studies. Studies using an observational design employing physical examination of patients showed higher prevalence than those relying on other methods such as medical notes or databases.

IMPLICATIONS OF KEY FINDINGS

Further prevalence and incidence studies are needed in Africa. Reporting of such studies should ensure items in the "Checklist for Prevalence Studies" from Joanna Briggs Institute (or similar well regarded resources) are addressed and the PICOS model and PRISMA guidelines are employed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Prospero registration number CRD42020180093.

International consensus on pressure injury preventative interventions by risk level for critically ill patients: A modified Delphi study

The aim of this modified Delphi study was to determine a minimum pressure injury preventative intervention set for implementation relative to critically ill patients' risk level. Preventative interventions were identified via systematic review, risk levels categorised by an intensive-care-specific risk-assessment-scale (COMHON Index), and panel members (n = 67) identified through an international critical care nursing body. Round 1: panel members were asked to rate implementation of 12 interventions according to risk level (low, moderate, high). Round 2: interventions were rated for use at the risk level which received greatest round 1 support. Round 3: interventions not yet achieving consensus were again rated, and discarded where consensus was not reached. Consensus indicated all patients should receive: risk assessment within 2-hours of admission; 8-hourly risk reassessment; and use of disposable incontinence pads. Additionally, moderate- and high-risk patients should receive: a reactive mattress support surface and a heel off-loading device. High-risk patients should also receive: nutritional supplements if eating orally; preventative dressings (sacral, heel, trochanteric); an active mattress support surface; and a pressure-redistributing cushion for sitting. Repositioning is required at least 4-hourly for low-risk, and 2-hourly for moderate- and high-risk patients. Rigorous application of the intervention set has the potential to decrease pressure injuries in intensive care.

Effects of cycle periods and pressure amplitudes of alternating pressure on sacral skin blood flow responses

BACKGROUND

There are no guidelines on selecting alternating pressure (AP) configurations on increasing sacral skin blood flow (SBF).

AIM

The specific aims were to compare different cycle periods and pressure amplitudes of AP on sacral SBF responses in healthy people to establish the efficacy and safety of the protocols.

METHODS

Two studies were tested, including the cycle period study (8 2.5-min vs 4 5-min protocols) and the pressure amplitude study (75/5 vs 65/15 mmHg protocols). Sacral SBF was measured using laser Doppler flowmetry (LDF) in 20 participants. AP loads were randomly applied using an indenter through the rigid LDF probe. Each protocol included a 10-min baseline, 20-min AP and 10-min recovery periods. A 30-min washout period was provided. The SBF response was normalized to the baseline SBF of each condition of each participant.

RESULTS

For the cycle period study, the 4 5-min cycle protocol partially restored more SBF than the 8 2.5-min cycle protocol at the low-pressure phase (0.87 ± 0.04 vs 0.71 ± 0.03, p < 0.05) and at the high-pressure phase (0.25 ± 0.03 vs 0.19 ± 0.03, p < 0.05). For the pressure amplitude study, the 75/5 mmHg protocol partially restored more sacral SBF than the 65/15 mmHg protocol at the low-pressure phase (0.87 ± 0.1 vs 0.25 ± 0.03, p < 0.05) but not at the high-pressure phase (0.23 ± 0.02 vs 0.21 ± 0.02, non-significant).

CONCLUSION

This study demonstrated that 1) a cycle period of 5 min was better than 2.5 min and 2) a pressure amplitude of 75/5 mmHg was better than 65/15 mmHg. The finding provides insights for selecting the AP configurations for increasing SBF.

Nurses' knowledge, attitudes, and behaviours related to pressure injury prevention: A large-scale cross-sectional survey in mainland China

AIMS AND OBJECTIVES

To determine the level of and factors in nurses' knowledge, attitudes and behaviours towards pressure injury (PI) prevention.

BACKGROUND

Although there has been a declining trend in global PI prevalence and hospital-acquired rates in recent years, this has not been the case in China. Evidence in the literature indicates the importance of nurses' knowledge, attitudes and behaviours for promoting PI prevention.

DESIGN

Cross-sectional study.

METHODS

A total of 1,806 nurses from 10 tertiary general hospitals in Hunan Province, China, participated in this study. Nurses' knowledge and attitudes were assessed using Pieper's Pressure Ulcer Knowledge Test and Attitude towards Pressure Ulcer Prevention Instrument, respectively, and behaviours were measured using a researcher self-designed questionnaire. Multiple logistic regression analysis determined factors affecting the nurses' PI-prevention knowledge, attitudes and behaviours. A STROBE checklist was used to report findings.

RESULTS

Among all nurses involved in this study, 41.7% had insufficient PI-prevention knowledge, 46.6% had negative PI-prevention attitudes, and 21.8% had poor PI-prevention behaviour. Nurses with a bachelor's degree or above were more likely to have adequate PI-prevention knowledge. Increased PI-prevention training frequency increased the nurses' positive attitude scores for PI prevention; longer years of service and a higher number of PI-prevention trainings attended predicted better PI-prevention behaviours.

CONCLUSION

Chinese nurses' PI-prevention knowledge and attitudes in this study were unsatisfactory, while their PI-prevention behaviour was acceptable. Increasing PI-prevention training frequency can help improve Chinese nurses' PI-prevention attitudes and further behaviour. Having a minimum of a bachelor degree may be beneficial to Chinese nurses' PI-prevention knowledge, but more evidence is needed.

RELEVANCE TO CLINICAL PRACTICE

Chinese nurses have insufficient knowledge about PI-repositioning, inadequate practices in PI nutrition assessment, and low confidence in their personal competence regarding PI-prevention. The key solution for the above issues is to promote ongoing education and training based on strong clinical leadership.

Hydrosurgical Debridement Allows Effective Wound Bed Preparation of Pressure Injuries: A Prospective Case Series

Background:

Pressure injuries (PIs) are common in hospitalized patients, with incidence exceeding 50% in high-risk patients. Immobilization causes a prolonged compression of vascular networks in tissues overlying bony prominences, leading to ischemia and ulceration. Traditionally, PIs are treated with a combination of surgical debridement and reconstruction. This approach can be invasive for debilitated patients who cannot tolerate prolonged surgeries and extensive tissue resection. Hydrosurgery uses high-pressure irrigation to low-invasively debride and cleanse wounds; its use has shown positive outcomes in burn and chronic wounds care. Here, we hypothesize that hydrosurgery allows low-invasive yet effective wound bed preparation in truncal PIs.

Methods:

We conducted a single-center, prospective, uncontrolled case series. Inclusion criteria for this study were presence of a truncal PI (stage III or IV) and an American Society of Anesthesiologists physical status of ≥2 (no exclusion criteria). Measured outcomes included duration of hydrosurgery, postsurgical local (dehiscence, infection, seroma) or systemic complications in the first 30 days, and PI recurrence rate (6-month follow-up).

Results:

Seven patients (3 sacral, 2 greater trochanteric, and 2 ischial tuberosity PIs) were enrolled for this study. Average duration of hydrosurgery was 12 minutes (±3.1). No local or systemic complications were observed at a 30-day follow-up (0/7, 0%). All flaps (6/7, 86%) and graft (1/7, 14%) reconstructions successfully survived, and no PI recurrence was reported within a 6-month follow-up (0/7, 0%).

Conclusions:

Hydrosurgery seems to allow safe, low-invasive, and effective wound bed preparation in truncal PIs. Larger controlled trials are needed to confirm this preliminary evidence, to guide its broader adoption for improved care of high-risk patients with PIs.