Nutrition strategies for pressure injury management: Implementing the 2019 International Clinical Practice Guideline

Use of a risk-based intervention bundle to prescribe and implement interventions to prevent pressure injury: An observational study

AIM

To explore the relationship between the prescription and implementation of pressure injury preventative interventions following risk assessment combined with a risk-stratified intervention bundle.

DESIGN

Single-centre, cross-sectional, observational, prospective.

METHODS

The charts and bedsides of 341 adult inpatients were examined. Data collection included pressure injury risk level, prescribed preventative interventions and evidence of intervention implementation.

RESULTS

Most patients (68.6%) were at risk of pressure injury, and most interventions were prescribed according to their risk level. However, evidence from direct observation and/or documentation indicated intervention implementation rates were relatively poor. Of nine interventions mandated for all patients, compliance with three patient-/carer-focused interventions was particularly poor, with evidence indicating they had been implemented for 3%-10% of patients. Also, nutritional screening-related interventions were implemented poorly. Clinically indicated implementation of heel-elevation devices and bariatric equipment was low for at-risk patients, and the implementation of interventions for patients with existing pressure injuries was suboptimal. Significant proportions of several interventions that were observed as having been implemented were not documented as such.

CONCLUSION

While most interventions were prescribed according to patient risk level, the overall implementation of interventions was poor. However, the results may in part be due to failure to document interventions as opposed to omitting them.

IMPLICATIONS FOR PATIENT CARE

Documentation of interventions is crucial as it provides evidence of the care provided. An increased focus on documentation of pressure injury preventative interventions is required, with a clear distinction between prescription and implementation.

IMPACT

The results highlighted several deficiencies in care, particularly relating to evidence of implementation, patient involvement and nutritional screening. The results from this study will be used to inform and improve future pressure injury prevention practice within the study hospital and should be used to inform and benchmark pressure injury preventative practices in other hospitals.

REPORTING METHOD

The study adheres to STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

None.

Eating at Risk within Long-Term Care: A Case for the Relational Ethics Lens

Within long-term care homes (LTCHs), conflicts occur between residents' desires, LTCH constraints, and healthcare providers' concerns about risks of harm. Due to the high prevalence of dysphagia and malnutrition in these settings, decisions regarding food choices are a common source of such tensions. Existing biomedical ethical models fail to capture the complexity of the interprofessional chronic care environment. This article proposes an alternative ethical lens, the relational ethics model. We describe a case illustrating the application of a decision-making framework with a relational ethics lens for a resident with severe dysphagia and malnutrition. We highlight how the bioethics model excludes important actors from ethical decision making. We encourage registered dietitians working in LTCH to incorporate a relational ethics model into their practice to help identify resident's values and bring attention to the interconnectedness of caring relationships and contextual factors. This approach can inform difficult decisions regarding the food and nutrition choices of residents and may facilitate meaningful outcomes for both individuals and the long-term care community.

Can a prolonged healing pressure injury be benefited by using an AI mattress? A case study

BACKGROUND

Pressure injuries are a common and serious issue for bedridden residents in long-term-care facilities. Areas of bony prominences, such as the scapula, sacrum, and heels, are more likely to develop pressure injuries. The management of pressure injury wounds include dressing changes, repositioning, away from moisture, decreasing the occurrence of friction and shear, and more. Some supportive surfaces are also used for pressure injury cases such as gel pads, alternating pressure air mattresses, and air-fluidized beds. The aim of this case study was to determine whether the use of an artificial intelligent mattress can improve a nursing home resident with prolonged pressure injury.

CASE PRESENTATION

A retrospective study design was conducted for this case study. A 79-year-old male developed a pressure injury in the sacrum. His pressure injury was initially at stage 4, with a score of 12 by the Braden scale. The PUSH score was 16. During 5.5 months of routine care plus the use of the traditional alternative air mattress, in the nursing home, the wound stayed in stage 3 but the PUSH score increased up to 11. An artificial intelligence mattress utilizing 3D InterSoft was used to detect the bony prominences and redistribute the external pressure of the skin. It implements a color guided schematic of 26 colors to indicate the amount of pressure of the skin.

RESULTS

The wound size was decreased and all eczema on the resident's back diminished. The PUSH score was down to 6, as the artificial intelligent mattress was added into the routine care. The staff also reported that the resident's quality of sleep improved and moaning decreased. The hemiplegic side is at greater risk of developing pressure injury.

CONCLUSIONS

This novice device appeared to accelerate wound healing in this case. In the future, more cases should be tested, and different care models or mattress can be explored.

The importance of taste on swallowing function

The world's population is aging. Pneumonia is the leading cause of death among the older adults, with aspiration pneumonia being particularly common. Aspiration pneumonia is caused by a decline in swallowing function. Causes can include age-related sarcopenia of swallowing muscles, cognitive decline, cerebrovascular and other diseases or even changes in individual taste preference. Currently, the main treatment approach for dysphagia is resistance training of swallowing-related muscles. This approach has not been effective and establishment of novel methods are required. In this review, we introduce and discuss the relationship between taste, taste preference, carbonation and swallowing function. Taste and preference improve swallowing function. Recently, it has been shown that a carbonated beverage that combines the functionality of a thickening agent, the appeal of taste, and the stimulation of carbonation improves swallowing function. This may be very useful in the recovery of swallowing function. It is important to note that deliciousness is based not only on taste and preference, but also on visual information such as food form. Umami taste receptors are expressed not only in taste buds but also in skeletal muscle and small intestine. These receptors may be involved in homeostasis of the amino acid metabolic network, i.e., the process of amino acid ingestion, intestine absorption, and storage in skeletal muscle. Proper stimulation of umami receptors in organs other than taste buds may help maintain nutritional status and muscle mass. Umami receptors are therefore a potential therapeutic target for dysphagia.

Nutritional factors and pressure injury risk in hospitalised patients post-stroke

OBJECTIVE

This study aimed to analyse the nutritional factors and pressure injury (PI) risk in hospitalised patients post-stroke.

METHOD

The research employed a descriptive observational method in which patients ≥18 years of age were followed for six days. Nutritional evaluation was based on anthropometric and dietary factors. The nutritional risk was assessed via anthropometric measurements, Braden nutrition subscale and daily dietary intake. PI risk was evaluated through the Braden Scale. The Wilcoxon test, paired t-test, and Kruskal-Wallis test were applied and corrected with Bonferroni correction or analysis of variance, followed by the post hoc Tukey test.

RESULTS

During their hospital stays, the participating 59 patients had an increase in sensory perception (p=0.02) and nutrition (p=0.005) scores. It was observed that patients at high risk of PI did not meet daily nutritional recommendations for calories, proteins, carbohydrates, lipids and micronutrients (zinc, selenium and copper) compared with patients at low-to-moderate risk. Weight (p<0.001), body mass index (p<0.001), calf (p=0.01) and arm (p=0.04) circumferences, and subscapular (p=0.003) and triceps (p<0.001) skinfolds decreased during the six days of hospitalisation.

CONCLUSION

From the findings of this study, it was concluded that nutritional factors, such as unmet recommended daily nutritional requirements of macronutrients and micronutrients, and nutritional status are associated with a higher risk of developing a PI.

The Clinical and Cost-Effectiveness of an Individualized Nutritional CAre (INCA) Bundle versus Standard Care for Adults with Pressure Injuries Receiving Home Nursing Services: A Protocol for a Cluster Randomized and Pragmatic Clinical Trial with an Economic Evaluation

BACKGROUND

Pressure injuries (PIs) represent a significant healthcare challenge in Singapore among the aging population. These injuries contribute to increased morbidity, mortality, and healthcare expenditure. Existing research predominantly explores single-component interventions in hospital environments, often yielding limited success. The INCA Trial aims to address this research gap by conducting a comprehensive, cluster randomized controlled trial that integrates education, individualized nutritional support, and community nursing care. This study is designed to evaluate clinical and cost-effectiveness outcomes, focusing on PI wound area reduction and incremental costs associated with the intervention.

METHODS

The INCA Trial employs a two-group, non-blinded, cluster randomized, and pragmatic clinical trial design, recruiting 380 adult individuals (age ≥ 21 years) living in the community with stage II, III, IV, and unstageable PI(s) who are receiving home nursing service in Singapore. Cluster randomization is stratified by postal codes to minimize treatment contamination. The intervention arm will receive an individualized nutrition and nursing care bundle (dietary education with nutritional supplementation), while the control arm will receive standard care. The 90-day intervention will be followed by outcome assessments extending over one year. Primary outcomes include changes in PI wound area and the proportion of participants achieving a ≥40% area reduction. Secondary outcomes include health-related quality of life (HRQOL), nutritional status, and hospitalization rates. Data analysis will be conducted on an intention-to-treat (ITT) basis, supplemented by interim analyses for efficacy and futility and pre-specified sensitivity and subgroup analyses. The primary outcome for the cost-effectiveness analysis will be based on the change to total costs compared to the change to health benefits, as measured by quality-adjusted life years (QALYs).

DISCUSSION

The INCA Trial serves as a pioneering effort in its approach to PI management in community settings. This study uniquely emphasizes both clinical and economic outcomes and melds education, intensive dietetic support, and community nursing care for a holistic approach to enhancing PI management.

Treatment of severe pressure ulcers with protein-enriched filtered platelet-rich plasma (PEFPRP): a possible management

Background: Biological dressings with non-transfusion blood components are among the treatments available for pressure ulcers (PUs). Biological dressings contain active concentrated pro-regenerative molecules that can modify and switch off local inflammatory pathways. This re-establishes the physiological homing, which results in healing. In our study, we used a biological component obtained by ultrafiltration of plasma-platelet concentrate: protein-enriched filtered platelet-rich plasma (PEFPRP) with a higher platelet and higher plasma protein concentration. We tested whether treatment with PEFPRP could improve healing in advanced-stage pressure ulcers with a large surface area. All the patients in this study had a surgical indication but were not able to undergo surgery for various reasons. Materials and methods: Ten patients with severe neurological disability and advanced-stage sacral pressure ulcers were treated with allogenic PEFPRP. The mean lesion surface area at T0 was 13.4 cm2 ( ± 9.8 SD). PEFPRP was derived from allogenic plasma-platelet apheresis that had been pre-ultrafiltered with a ProSmart™ filter (Medica, Italy) to obtain a concentration after filtration of the plasma protein (12-16 g/dL) and platelet (1-1.2 x 106 microL). Results and Conclusion: All cases showed a reduction in the surface area of the pressure ulcer and in the Pressure Ulcer Scale for Healing (PUSH) score. The mean reduction values at week 6 were as follows: -52% for surface area and -21% for PUSH. Rapid wound healing is fundamental to avoid infections and improve patients' quality of life. This blood component builds new tissue by creating a new extracellular matrix. This, in turn, promotes rapid restoration of the three-dimensional structure of the tissue necessary for healing deeper wounds. PEFPRP shrinks the PU and improves its morphological features (reducing undermining and boosting granulation tissue). PEFPRP also promotes tissue restoration, obtaining an optimal scar. It is a safe and feasible treatment, and these preliminary results support the use of PEFPRP in the treatment of pressure ulcers. PEFPRP dressings could be integrated in the standard treatment of advanced-stage PU.

Neutrophil heterogeneity and aging: implications for COVID-19 and wound healing

Neutrophils play a critical role in the immune response to infection and tissue injury. However, recent studies have shown that neutrophils are a heterogeneous population with distinct subtypes that differ in their functional properties. Moreover, aging can alter neutrophil function and exacerbate immune dysregulation. In this review, we discuss the concept of neutrophil heterogeneity and how it may be affected by aging. We then examine the implications of neutrophil heterogeneity and aging for COVID-19 pathogenesis and wound healing. Specifically, we summarize the evidence for neutrophil involvement in COVID-19 and the potential mechanisms underlying neutrophil recruitment and activation in this disease. We also review the literature on the role of neutrophils in the wound healing process and how aging and neutrophil heterogeneity may impact wound healing outcomes. Finally, we discuss the potential for neutrophil-targeted therapies to improve clinical outcomes in COVID-19 and wound healing.

Attitude and preventive practices of pressure ulcers among orthopedic nurses in a tertiary hospital in Ghana

BACKGROUND

Pressure ulcers (PUs), which affect millions of people worldwide, are among the five most prevalent hospitalized cases causing adverse impairment. Nevertheless, pressure ulcers are largely preventable, and their management depends on their severity. The authors, therefore, explored the attitude and preventive practices of pressure ulcers among orthopedic nurses in a tertiary hospital in Ghana.

METHODS

An exploratory descriptive qualitative approach was employed for this study to help researchers explore the attitude and practices toward PU (Pressure Ulcer). Purposive sampling approach was employed, and data was analyzed using thematic content analysis. The sample size for this study was 30 which was obtained based on saturation. Participants were engaged in face-to-face interviews which were transcribed verbatim.

FINDINGS

Two themes and eight subthemes were generated from the analysis of this study. The two themes were preventive practices and attitude towards PU. The study identified that there were no specific protocols illustrated on the wards for managing pressure ulcers. Nevertheless, the study participants were keen on preventing pressure ulcers and hence engaged in practices such as early patients' ambulation, early identification of PU signs, removing creases and crumps from patient beds, nutritional management for PU prevention, and dressing of PU wounds.

CONCLUSION

Practices of pressure ulcer management were highly valued by the orthopedics nurses. Hence, the nurses recommended the need for accepted guidelines on pressure ulcer management to be illustrated in the various orthopedic wards in the country.

Pilot Study on the Relationship between Malnutrition and Grip Strength with Prognosis in Diabetic Foot

Sarcopenia and malnutrition have been associated in the elderly population with a poor prognosis in wound healing and with other adverse events, such as institutionalization or functional impairment. However, it is not known how these factors influence the prognosis of diabetic foot in the elderly. To answer this question, a prospective observational study of 45 patients over 65 years of age admitted with diagnoses of diabetic foot in a tertiary hospital has been conducted. All patients were assessed at admission and at 3 months after returning home to determine quality of life, pain, mobility and healing, overall hospital stay in relation to the presence of malnutrition (measured by BMI, CIPA scale and analytical parameters at admission of serum proteins and albumin), and sarcopenia measured by grip force, among other geriatric syndromes. The results found a relationship between altered sarcopenia and more pain and poorer quality of life, and altered BMI was related to a lower cure rate and worse mobility at follow-up. This study seems to indicate that, in the elderly population with diabetic foot, malnutrition and sarcopenia should be managed at the same time as the treatment of the diabetic foot itself.

Relationship between Nutritional Risk, Clinical and Demographic Characteristics, and Pressure Ulcers in Patients with Severe Acquired Brain Injuries Attending a Rehabilitative Program

Preliminary evidence in the literature suggests a high prevalence of malnutrition (undernutrition) in patients with severe acquired brain injuries (sABI), with an expected negative impact on clinical outcomes and pressure ulcers (PUs) in particular. In a retrospective cohort study on patients discharged from intensive care units (ICU) and admitted to an intensive rehabilitation unit (IRU), the risk of malnutrition was systematically assessed, in addition to standard clinical procedures (including PUs evaluation), using two different tools: the Malnutrition Universal Screening Tool (MUST) and the Controlling Nutritional Status (CONUT) tool. Eighty-eight patients were included in the analysis. A high proportion (79.5%) of patients with sABI suffered from PUs, being older and more frequently men, with a longer ICU stay between the event and admission to IRU, and a greater MUST score. At discharge, when compared to patients whose PUs had healed, those with persisting PUs were more often men and had the worst cognitive performance at admission. As for nutritional risk, the baseline CONUT score was identified as an independent negative predictor of PUs at discharge by the logistic regression model. In conclusion, the assessment of nutritional risk using simple standard tools may be useful in the clinical evaluation of sABI patients with PUs.

Closure of pressure injury and mortality in internal medicine wards

PURPOSE

The prevalence of pressure injury (PI) in hospitalized patients ranges from 5 to 15%, and is significantly greater in critical care and palliative care units. Prevalence of PI is considered an indicator of health care quality and is associated with increased morbidity and mortality. The study aims to determine the features of PI and its association with mortality among hospitalized patients in the inpatient service of a university hospital.

METHODS

The present study comprised 89 patients hospitalized on the internal medicine inpatient service who had PI at the time of hospitalization and or who developed PI during hospitalization. Patients were categorized based on the state of PI closure (complete/incomplete). Mortality rates for 1 month, 3 months, 6 months, and 1 year were computed.

RESULTS

The median age was 74. (IQR: 62-82). Forty-eight patients were female, and 15.7% of hospitalized patients had PI. A third of patients died during their index hospitalization. Patients with completely closed PI had decreased one-month, three-month, six-month, and one-year mortality rates. Complete closure of PI influenced all four mortality rates independently of other parameters, as determined by Cox regression analysis of the factors impacting mortality.

CONCLUSION

As life expectancy rises, the frequency of PI increases, resulting in a rise in health care expenses. To reduce these expenses, prevention, early identification, and treatment of PI are essential. The primary finding of the study is that complete closure of PI in hospitalized patients reduces the risk of death.

Exploring nursing-sensitive events in home healthcare: A national multicenter cohort study using a trigger tool

BACKGROUND

The provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of adverse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not received sufficient scientific attention.

OBJECTIVES

To explore nursing-sensitive events in patients receiving home healthcare.

DESIGN, SETTING AND PARTICIPANTS

A Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country.

METHODS

Ten trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes.

RESULTS

In total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing-sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficiencies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization.

CONCLUSIONS

Nursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.

Effect and Mechanism of Dragon's Blood on Wound Healing of Patients with Stress Hand Injury

This study aimed to explore the effect and mechanism of Dragon's Blood on wound healing in patients with a pressure hand injury. A total of 120 patients with pressure hand injury treated in our hospital were randomly divided into two groups. Sixty patients in the control group were dressed with sterile gauze, and 60 patients in the observation group were smeared with blood exhaustion. The clinical effects and serological indexes of the two groups were compared, and the mechanism of wound healing was analyzed. The results showed that the treatment effective rate of the control group was 80% and that of the observation group was 93.33%. The treatment effective rate of the observation group was dramatically higher (P < 0.05). The number of patients with good granulation tissue in the observation group was 53, which was dramatically greater than that in the control group. The number of patients with a small amount of wound exudation was 51, which was dramatically greater than that in the control group (P < 0.05). After treatment, the levels of matrix metalloproteinase (MMP-3), vascular endothelial growth factor (VEGF), and transforming growth factor B1 (TGF-B1) in the observation group increased more dramatically (P < 0.05). The level of tissue inhibitor of metalloproteinase-1 (TIMP-1) decreased to 617.23 ng/L in the observation group, and the degree of reduction was more obvious (P < 0.05). Notably, Dragon's Blood promoted wound healing at the injury site by increasing the levels of MMP-3, VEGF, and TGF-B1and decreasing TIMP-1. The area of wound reduction in the observation group was 0.27 cm², and the reduction was more obvious (P < 0.05). The healing time of pressure hand injury in the observation group was 15.27 days, which was dramatically shorter (P < 0.05). In summary, Dragon's Blood had a good effect on the healing of the injured site in patients with pressure hand injury, which is worthy of promotion.

Nutritional Management in a 101-Year-Old Woman with Physical Inactivity and General Weakness: A Case Report

Japan has the world's highest life longevity, and centenarian patients are no longer rare. However, sufficient information related to centenarians is not available. Herein, we report the case of a 101-year-old centenarian woman who recovered from extreme inactivity and general weakness, mainly through nutritional management at home, to understand instances of nutritional management in centenarians. The patient developed lethargy, with a rapid decline in activity levels and food intake. She was diagnosed with senility by a primary doctor. We concluded that she had no problems with feeding and swallowing and predicted that her motivation to eat had decreased. We planned an intervention that lasted three months. To reduce the risk of aspiration, we paid attention to her posture while eating. To stimulate her appetite, we increased the variety and color of food items. To consider both the texture of food and safety, we changed the form of foods from paste (IDDSI Level 4)-like to solid food of regular size as much as possible. We recommended that the patient consume her favorite sweet between meals to enjoy eating. Two and half months after the initial intervention, the patient's inactivity and general weakness improved dramatically, which was recognized by her willingness to eat, laugh loudly, and hum, although she could not speak clearly. The patient finally was able to have dinner with her family.