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

Skin injury: Associations with variables related to perfusion and pressure

Skin injuries are a major healthcare problem that are not well understood or prevented in the critically ill, suggesting that underappreciated variables are contributing. This pilot study tested the hypothesis that perfusion-related factors contribute to skin injuries diagnosed as hospital-acquired pressure injuries (HAPIs). A total of 533 adult patients were followed over 2574 critical care days (mean age 62.4, standard deviation (SD) 14.3 years, mean body mass index 30.4 (SD 7.4) kg/m2, 36.4% female). This was a secondary analysis of prospective, non-randomised clinical data from an intensive care unit at a large urban teaching hospital. Factors related to perfusion, specifically two or more infusions of vasopressors/inotropes, temporary mechanical circulatory support (MCS), extracorporeal membrane oxygenation, and durable MCS, were analysed to determine whether they were more strongly associated with HAPIs than immobility due to prolonged mechanical ventilation (>72 h) or operating room time (>6 h). Patients diagnosed with a HAPI had a statistically significant higher risk of being exposed to variables related to perfusion and immobility (P < 0.05 for each variable). Perfusion-related variables, except durable MCS, had a larger effect on skin breakdown (number needed to harm (NNH) 4-10) than immobility-associated variables (NNH 12-17). The finding that perfusion-related variables predicted HAPIs may warrant consideration of alternative diagnoses, such as skin failure due to impaired perfusion as a pathophysiological process that occurs concurrently with multisystem organ failure. Differentiation of skin injuries primarily from circulatory malfunction, rather than external pressure, may guide the development of more effective treatment and prevention protocols. This pilot study suggests that the contribution of perfusion to skin injuries should be explored further.

Prophylactic dressings to prevent sacral pressure injuries in adult patients admitted to intensive care units: A three-arm feasibility randomized controlled trial

BACKGROUND

Pressure injuries in intensive care patients are a safety issue. Specialized foam sacral prophylactic dressings prevent pressure injuries with several products available for clinicians to choose from.

OBJECTIVES

Assess the feasibility of conducting a multisite trial to test the effectiveness of two dressings versus usual care in preventing sacral pressure injuries in intensive care patients.

METHODS

Using a three-arm pilot randomized trial design, adult intensive care unit patients at risk for pressure injuries were randomly allocated to the Mepilex® Sacrum dressing, the Allevyn™ Life Sacrum dressing or the control group. Daily pressure injury data were collected including a de-identified sacral photograph, which the blinded outcome assessor used to determine the study end point: a new sacral pressure injury. Pre-determined feasibility criteria were measured in terms of eligibility, recruitment, retention, intervention fidelity and missing data.

RESULTS

From May-September 2021, we screened 602 intensive care unit adult patients for eligibility with 93 % (n = 558) excluded. Forty-four (7 %) were eligible, and all were recruited and randomized (100 %). After receipt of the intervention two participants withdrew from the study. Our final sample of 42 participants were randomly allocated to the Mepilex® (n = 12), Allevyn™ (n = 14) or control (n = 16) group. The interventions were delivered as intended and there were 11 (6 %) cases of missing outcome data. Five participants (12 %) developed a sacral pressure injury, four of whom received a sacral dressing.

CONCLUSIONS

A larger trial is feasible with minor refinement to the length of stay eligibility criterion.

IMPLICATIONS FOR PRACTICE

Prophylactic sacral dressings are recommended for pressure injury prevention. Determining the feasibility of a larger trial to test the effectiveness of two dressings versus usual care in preventing sacral pressure injuries in intensive care patients can provide evidence to aid clinicians, policy makers and managers make value-based care decisions.

Hospital-acquired pressure ulcers among adult ICU patients in tertiary hospitals in Oman: a one-year prevalence study

BACKGROUND

Hospital-acquired pressure ulcer (HAPU) is a significant problem in healthcare settings and is associated with negative impacts on patient health. Although monitoring of pressure ulcers (PUs) among hospitalised patients was started more than a decade ago in Oman, no previous studies have been completed to estimate the prevalence and risk factors of HAPUs among patients in the intensive care unit (ICU). The aim of this study was to estimate the prevalence and identify risk factors for HAPUs among adult ICU patients in selected tertiary hospitals in Oman.

METHOD

A retrospective, cross-sectional, nested, case-control design was used to identify the prevalence rate of HAPUs and risk factors for a cohort of adult ICU patients over one calendar year (1 January-31 December 2019) in two tertiary hospitals in Oman.

RESULTS

The prevalence rate for HAPU among ICU patients in Oman was 36.4%. However, when excluding cases of stage 1 ulcer, the rate was 30.37%. The most prevalent location was the sacrum (64.1%), and the most common stage was stage 2 (73.1%). The risk factors for HAPU included male sex (odds ratio (OR): 0.37; p=0.023), organ failure (OR: 3.2; p=0.033), cancer (OR: 3.41; p=0.049), cerebrovascular accident (OR: 12.33; p=0.001), mechanical ventilator (OR: 9.64; p=0.025) and ICU length of stay (OR: 1.24; p<0.001).

CONCLUSION

HAPUs among ICU patients constitute a significant problem associated with severe clinical consequences and result in substantial adverse healthcare outcomes worldwide, including in Oman. Identifying the risk factors and the impact on the healthcare system is the foundation for preventing and managing HAPUs.

Impact of head-of-bed elevation angle on the development of pressure ulcers and pneumonia in patients on mechanical ventilation: a systematic review and meta-analysis

BACKGROUND

Mechanical ventilation is crucial for patient management in intensive care units, but it comes with complications such as pressure ulcers and ventilator-associated pneumonia (VAP). The impact of head-of-bed elevation angles on these complications remains a critical area for investigation.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines and involved searches across PubMed, Embase, Web of Science, and Cochrane Library, conducted on September 19, 2023, with no date or language restrictions. We included randomized controlled trials that compared different head-of-bed elevation angles in adult ICU patients on mechanical ventilation. Data were extracted on study characteristics, quality assessed using the Cochrane risk of bias tool, and statistical analyses performed using chi-square tests for heterogeneity and fixed or random-effects models based on heterogeneity results.

RESULTS

Six studies met inclusion criteria out of an initial 601 articles. These studies showed minimal heterogeneity (I2 = 0.0% for pressure ulcers, p = 0.930; and for VAP, p = 0.797), supporting the use of fixed-effect models. Results indicated that a higher elevation angle (45°) significantly increased the risk of pressure ulcers (OR = 1.95, 95% CI: 1.12-3.37, p < 0.05) and decreased the incidence of VAP compared to a lower angle (30°) (OR = 0.51, 95% CI: 0.31-0.84, p < 0.05).

CONCLUSIONS

While higher head-of-bed elevation can reduce the risk of VAP in mechanically ventilated patients, it may increase the risk of pressure ulcers. Clinical strategies should carefully balance these outcomes to optimize patient care in ICU settings.

REGISTRATION

PROSPERO 2024 CRD42024570232.

Increased Risk and Unique Clinical Course of Patient Safety Indicator-3 Pressure Injuries Among COVID-19 Hospitalized Patients

BACKGROUND

The COVID-19 pandemic introduced unique challenges to healthcare systems, particularly in relation to patient safety and adverse events during hospitalization. There is limited understanding of COVID-19's association with some patient safety indicators (PSIs).

OBJECTIVES

This study aimed to investigate the impact of COVID-19 infection on the rate of PSI-3 events and its implications on quality metrics. We compared PSI-3 event rates between COVID-19-infected and uninfected patients and examined the clinical characteristics of COVID-19 patients experiencing PSI-3 events.

METHODS

This is a retrospective study at Mayo Clinic hospitals between January 2020 and February 2022, analyzing patients meeting PSI-3 denominator eligibility criteria. PSI-3 events were identified using AHRQ WinQI software. Patients were categorized based on COVID-19 status. Patient demographics, characteristics, and PSI-3 rates were compared. A case series analysis described clinical details of COVID-19 patients with PSI-3 events.

RESULTS

Of 126,781 encounters meeting PSI-3 criteria, 8674 (6.8%) had acute COVID-19 infection. COVID-19-infected patients were older, more likely to be male, non-white, and had private insurance. PSI-3 rates were significantly higher in COVID-19 patients (0.21% versus 0.06%, P < 0.0001), even after risk adjustment (adjusted risk ratio, 3.24, P < 0.0001). The case series of 17 COVID-19 patients with PSI-3 events showed distinctive clinical characteristics, including higher medical device-related pressure injuries, and greater predisposition for head, face, and neck region.

CONCLUSIONS

Acute COVID-19 infection correlates with higher PSI-3 event rates. Current quality indicators may require adaptation to address the pandemic's complexities and impact on patient safety. Further research is needed to comprehensively understand the intricate relationship between COVID-19 and patient outcomes.

The Chinese Mandarin COMHON Index and Braden Scale to assess pressure injury risk in intensive care: An inter-rater reliability and convergent validity study

BACKGROUND

The COMHON Index is an intensive-care-specific pressure injury risk assessment tool, which has demonstrated promising psychometric properties. It has been translated into Chinese Mandarin but requires inter-rater reliability testing and comparison to the standard care instrument (Braden Scale) before clinical use.

OBJECTIVES

This study aimed to test and compare the inter-rater reliability and convergent validity of the Chinese Mandarin versions of the COMHON Index and Braden Scale.

METHODS

The study was conducted in a Chinese comprehensive intensive care unit. Based on a sample size calculation, five registered nurse raters with at least 6-months experience independently conducted risk assessments for 20 adult patients using both the COMHON Index and Braden Scale. Intraclass correlations (ICC) for inter-rater reliability, standard errors of measurement (SEM), and minimally detectable change (MDC) were calculated. Convergent validity was assessed using Pearson Product Moment Correlation for sum scores and Spearman's rho for subscales.

RESULTS

Inter-rater reliability of COMHON Index and Braden Scale sum scores was very high (ICC [1,1] = 0.973; [95% confidence interval 0.949-0.988]; SEM 0.54; MDC 1.50) and high (ICC [1,1] = 0.891; [95% confidence interval 0.793-0.951]; SEM 0.93; MDC 2.57), respectively. All COMHON-Index subscales demonstrated ICC values >0.6, whereas two Braden Scale subscales (Mobility, Activity) were below this threshold. Instrument sum scores were strongly correlated (Pearson's r = -0.76 [r2 = 0.58]; p < 0.001), as were three subscale item pairs (mobility rs= -0.56 [r2 = 0.32]; nutrition rs= -0.63 [r2 = 0.39]; level of consciousness/sensory perception rs= -0.67 [r2 = 0.45] p < 0.001).

CONCLUSION

Both the COMHON Index and Braden Scale demonstrated high levels of inter-rater reliability and measured similar constructs. However, the COMHON Index demonstrated superior inter-rater reliability and the results suggest that it better detects changes in patient condition and subsequently pressure injury risk. Further testing is recommended.

Association of norepinephrine with pressure ulcer development in critically ill patients with COVID-19-related acute respiratory distress syndrome: A dose-response analysis

OBJECTIVES

To investigate the correlation between varying doses of norepinephrine (NE) and the incidence of pressure injuries (PIs) in COVID-19 patients in intensive care units (ICUs).

DESIGN

A retrospective multicenter study was conducted on 1,078 COVID-19 patients admitted to ICUs with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. The research spanned from March 2020 to April 2021 across five university-affiliated hospitals in Iran. Univariate and multivariate binary logistic regression analyses, along with linear and non-linear dose-response assessments, were utilized to evaluate the relationship between NE dosages and the probability of PI development.

FINDINGS

The multivariate analysis revealed a significant association between higher doses of NE administered over 24 h (OR: 1.832, 95 % CI: 1.218-2.754, P=0.004) and cumulative doses (OR: 1.408, 95 % CI: 1.204-1.975, P=0.048) with the occurrence of PIs. Moreover, patients receiving high NE doses had a nearly fourfold increased risk of developing PIs, regardless of PIs stage, compared to those on low or moderate doses (>15 µg/min vs. ≤ 15 µg/min; OR: 4.401, 95 % CI: 3.339-5.801, P=0.001). Although the linear dose-response analysis did not show a significant correlation between NE doses (µg/min) and PI development (P>0.05), the non-linear analysis indicated that NE doses ≤ 9 µg/min were associated with a reduced risk of PI development.

CONCLUSION

Maintaining NE infusion within the range of 1-9 µg/min appears to be most effective in reducing the likelihood of PIs in ICU patients with COVID-19. Lower NE doses (≤9 µg/min) were associated with a lower risk of PI development, suggesting that factors beyond NE dosage or the use of other vasopressors may play a crucial role in PI formation in this patient cohort.

IMPLICATIONS FOR CLINICAL PRACTICE

Rather than suggesting a specific threshold, clinicians should consider further studies to determine the optimal dose that balances microvascular perfusion and patient outcomes. It is crucial to comprehensively evaluate additional factors and selectively use vasopressors. Individualized care, including regular monitoring and personalized treatment plans, is essential for achieving the best outcomes in this patient population.

Effectiveness of specialised support surface modes in preventing pressure injuries in intensive care: A systematic review and meta-analysis

BACKGROUND

Patients in intensive care units (ICU) are at an increased risk of pressure injuries. In ICUs, specialised support surfaces are an intervention often used to prevent pressure injuries. This systematic review and meta-analysis aimed to ascertain the effectiveness of different specialised support surface modes for preventing pressure injuries to adult ICU patients.

METHODS

Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, PEDro, Cochrane Library, Clinicaltrials.gov and eligible paper references were searched for appropriate studies. Studies were included if they investigated both dynamic support surface modes low-air-loss (LAL) and alternating pressure (AP), involved adult ICU patients (≥18 years old), and investigated pressure injury incidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Mixed Methods Appraisal Tool (MMAT) checklists were used for reporting and quality assessment. Risk ratios (RRs) with 95 % Confidence Intervals (CIs) were used to summarise pressure injury incidence. The pooled RR was calculated with the random-effects model using the Mantel-Haenszel method. Further secondary analysis examined length of stay (LoS) and severity of illness.

RESULTS

The four included studies involved 3,308 patients. These studies were heterogeneous in design. When AP surface mode was compared with LAL surface mode, there was no significant difference in the occurrence of pressure injury (8.9 % versus 10.9 %, RR 0.64). Mattress mode also had no direct association with length of stay and severity of illness.

CONCLUSION

This systematic review and meta-analysis found no significant difference in the effectiveness of LAL and AP support surface modes in preventing pressure injuries in adult ICU patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians should remember that mattresses are just one element within strategies to prevent pressure injuries in ICUs. The equivocal findings of this systematic review highlight the complexity of preventing pressure injuries and underscore the importance of holistic nursing care.

Associations between body mass index and interface pressure after 3 h loading in healthy adults

AIM OF THE STUDY

The purpose of this study was to determine the associations between body mass index and interface pressure after 3 h loading in healthy adults and to establish a foundation for the development of interventions tailored to body mass index.

MATERIAL AND METHODS

A secondary data analysis based on a clinical trial involving 75 adults was conducted. Data were analyzed using descriptive statistics, repeated measure ANOVA, and ANCOVA. The statistics program IBM SPSS Statistics 27.0 was used for data analysis.

RESULTS

Loading caused a significant increase in average pressure in the obesity group compared to the underweight group. There was a significant increase in risk area ratio calculated based on 30 mmHg and 45 mmHg in both obesity and overweight groups compared to the underweight group. On both support surfaces, average pressure, peak pressure, and risk area ratio were higher in the obese group compared to the normal weight group. However, these differences were not statistically significant.

CONCLUSION

Given the emphasized risk of pressure injuries, long-term observation of body mass index-specific changes in interface pressure can provide crucial evidence for pressure injury prevention nursing. The results of this study suggest the need to implement pressure injury prevention interventions that consider the pressure characteristics according to BMI.

Psychometric properties of the Braden scale to assess pressure injury risk in intensive care: A systematic review

OBJECTIVE

To analyse the psychometric properties of the Braden scale to assess pressure injury risk in adults in intensive care.

DESIGN

A systematic review was conducted, with literature searches undertaken in five electronic databases. No date limits were applied. Selection, data extraction and risk of bias assessment were completed by two reviewers independently. A customised data extraction template was used, with risk of bias conducted using the COSMIN Risk of Bias checklist. Data were analysed using narrative synthesis.

RESULTS

Thirty-four studies met inclusion criteria. Two studies reported internal consistency with Cronbach's alpha ranging from poor (0.43) to good (0.85). For interrater reliability, only four studies reported intraclass correlation, ranging from 0.66 to 0.96 for Braden sum score. Three studies reported convergent validity, with strong associations found between the COMHON Index (r = 0.70), Cubbin-Jackson scale (r = 0.80), and Norton scale (r = 0.77), but contrasting associations with the Waterlow score (r = 0.22 to 0.72). A large majority of studies reported predictive validity (n = 29), with wide variability. Several studies investigated optimal cut-off scores, with the majority indicating this was in the range of 12-14.

CONCLUSIONS

This review demonstrates inconsistency in the psychometric properties of the Braden scale in ICU settings. Further research is needed to determine suitability of the Braden scale for ICU before it can be recommended as standard for clinical practice, including comparison with other ICU-specific risk assessment tools.

IMPLICATIONS FOR CLINICAL PRACTICE

When used in ICU, the reliability, validity and reported cut-off scores of the Braden scale are variable. As a predictive tool, the scale should be used cautiously. In ICU, the value of the Braden scale resides in its ability to identify patients that are most at risk of developing a pressure injury and to implement preventative measures to mitigate identified risk factors.

Body mass index and pressure injuries risk in hospitalized adult patients: A dose-response analysis

BACKGROUND

The association between underweight and pressure injuries (PIs) has been established in several studies. However, there is a lack of well-designed research investigating the connection between overweight and obesity with these injuries.

OBJECTIVE

This meta-analysis aims to investigate the dose-response relationship between body mass index (BMI) and the risk of PIs in adult hospitalized patients.

METHODS

PubMed, Web of Science, and MEDLINE Databases were searched from inception to May 2024. Observational articles with at least three BMI categories were included in the study. BMI was defined as underweight, normal weight, overweight, and morbid obesity for the meta-analysis. The non-linear relationship between BMI and the risk of PIs in hospitalized adults was investigated using restricted cubic spline models. Fractional polynomial modeling was used.

RESULTS

Eleven articles reporting at least 3 categories of BMI met the inclusion criteria, including 31,389 participants. Compared to patients with normal weight, those with underweight, obesity, and morbid obesity exhibited an increased risk of PIs, with odds ratios of 1.70 (95%CI:1.50-1.91), 1.12 (95%CI:1.02-1.24), 1.70 (95%CI:1.13-2.55), respectively. A J-shaped dose-response model was established for the relationship between PI risk and BMI (Pnon-linearity < 0.001, Plinearity = 0.745).

CONCLUSION

The J-shaped dose-response pattern revealed that underweight, obesity and morbid obesity heightened the risk of PIs in hospitalized adults. Lower and higher BMI values may signify an increased risk for PIs, particularly among the elderly with lower BMI, providing valuable guidance for medical staff.

Prediction model of pressure injury occurrence in diabetic patients during ICU hospitalization--XGBoost machine learning model can be interpreted based on SHAP

BACKGROUND

The occurrence of pressure injury in patients with diabetes during ICU hospitalization can result in severe complications, including infections and non-healing wounds.

AIMS

The aim of this study was to predict the occurrence of pressure injury in ICU patients with diabetes using machine learning models.

STUDY DESIGN

In this study, LASSO regression was used for feature screening, XGBoost was employed for machine learning model construction, ROC curve analysis, calibration curve analysis, clinical decision curve analysis, sensitivity, specificity, accuracy, and F1 score were used for evaluating the model's performance.

RESULTS

Out of the 503 ICU patients with diabetes included in the study, pressure injury developed in 170 cases, resulting in an incidence rate of 33.8 %. The XGBoost model had a higher AUC for predicting pressure injury in patients with diabetes during ICU hospitalization (train: 0.896, 95 %CI: 0.863 to 0.929; test: 0.835, 95 % CI: 0.761-0.908). The importance of SHAP variables in the model from high to low was: 'Days in ICU', 'Mechanical Ventilation', 'Neutrophil Count', 'Consciousness', 'Glucose', and 'Warming Blanket'.

CONCLUSION

The XGBoost machine learning model we constructed has shown high performance in predicting the occurrence of pressure injury in ICU patients with diabetes. Additionally, the SHAP method enables the interpretation of the results provided by the machine learning model.

RELEVANCE TO CLINICAL PRACTICE

Improve the ability to predict the early occurrence of pressure injury in diabetic patients in the ICU. This will enable clinicians to intervene early and reduce the occurrence of complications.

Pressure ulcer risk assessment in the ICU. Is it time for a more objective measure?

BACKGROUND

The Braden scale, one of the most widely used risk assessment tools is often criticized when used in the Intensive Care Unit. Most patients in the Intensive Care Unit are at risk of pressure ulcer development meaning that the Braden score will usually indicate high risk for these patients. This study set out to determine the correlation between Sub-Epidermal Moisture measurements and Braden scores among Intensive Care Unit patients.

METHODS

This study employed an observational research design. Braden score was assessed on all study days (1-5), in addition to visual skin assessment and Sub-Epidermal Moisture measurements at the sacrum and heels. Sub-Epidermal Moisture measurements were categorised as low (<0.5), borderline abnormal (≥0.5), and high (≥0.8). Correlation was assessed between Sub-Epidermal Moisture levels and Braden scores.

RESULTS

A total of 53 participants were recruited. The median (interquartile range) baseline Braden score was 9 (9-10) and 81 % (n = 43) of participants were at very high/high risk of pressure ulcer development. Braden scores remained relatively constant over time with little fluctuation in scores. 19 % (n = 10) of patients had normal (<0.5) Sub-Epidermal Moisture delta measurements on enrolment, and all developed abnormal measurements by day 2. There were no significant correlations between Braden scores and Sub-Epidermal Moisture measurements.

CONCLUSION

Although this was not its original intention, a missing link with the Braden scale is that it does not provide information on how patients are responding to the adverse effects of pressure and shear forces. Furthermore, in patients who are critically unwell, most patients are classified as being "at risk" of pressure ulcer development. Therefore, an objective measure of how patients are responding to pressure and shear forces at different anatomical areas is needed.

IMPLICATIONS TO CLINICAL PRACTICE

Sub-Epidermal Moisture measurements can offer more information, not only on identifying those who are at risk, but also how those patients are tolerating this risk at different anatomical sites.

Adverse Events during Prone Positioning of Patients with COVID-19 during a Surge in Hospitalizations-Results of an Observational Study

This study aimed to determine the prevalence of adverse events in mechanically ventilated adults with COVID-19 who have undergone prone positioning. A total of 100 patients were included retrospectively; 60% were males, the mean age was 64.8 ± 9.1 years, and hospital mortality was 47%. In all, we recorded 118 removals of catheters and tubes in 66 patients; 29.6% were removals of a nasogastric tube, 18.6% of an arterial line, 14.4% of a urinary catheter, and 12.7% of a central venous catheter. Reintubation or repositioning of a tracheotomy tube was required in 19 patients (16.1%), and cardiopulmonary resuscitation in 2 patients (1.7%). We recorded a total of 184 pressure ulcers in 79 patients (on anterior face in 38.5%, anterior thorax in 23.3% and any extremity anteriorly in 15.2%). We observed that body weight (p = 0.021; β = 0.09 (CI95: 0.01-0.17)) and the cumulative duration of prone positioning (p = 0.005; β = 0.06 (CI95: 0.02-0.11)) were independently associated with the occurrence of any adverse event. The use of prone positioning in our setting was associated with a greater number of adverse events than previously reported. Body weight and cumulative duration of prone positioning were associated with the occurrence of adverse events; however, other factors during a COVID-19 surge, such as working conditions, staffing, and staff education, could also have contributed to a high prevalence of adverse events.

Improving pressure ulcer care in intensive care units: Evaluating the impact of bundled care and silver nanoparticle dressings

BACKGROUND

Pressure ulcer (PU) are prevalent among critically ill trauma patients, posing substantial risks. Bundled care strategies and silver nanoparticle dressings offer potential solutions, yet their combined effectiveness and impact on patient satisfaction remain insufficiently investigated.

AIM

To assess the impact of bundled care along with silver nanoparticle dressing on PUs management and family satisfaction in critically ill trauma patients.

METHODS

A total of 98 critically ill trauma patients with PUs in intensive care unit (ICU) were included in this study. Patients were randomly assigned to either the control group (conventional care with silver nanoparticle dressing, n = 49) or the intervention group (bundled care with silver nanoparticle dressing, n = 49). The PU Scale for Healing (PUSH) tool was used to monitor changes in status of pressure injuries over time. Assessments were conducted at various time points: Baseline (day 0) and subsequent assessments on day 3, day 6, day 9, and day 12. Family satisfaction was assessed using the Family Satisfaction ICU 24 questionnaire.

RESULTS

No significant differences in baseline characteristics were observed between the two groups. In the intervention group, there were significant reductions in total PUSH scores over the assessment period. Specifically, surface area, exudate, and tissue type parameters all showed significant improvements compared to the control group. Family satisfaction with care and decision-making was notably higher in the intervention group. Overall family satisfaction was significantly better in the intervention group.

CONCLUSION

Bundled care in combination with silver nanoparticle dressings effectively alleviated PUs and enhances family satisfaction in critically ill trauma patients. This approach holds promise for improving PUs management in the ICU, benefiting both patients and their families.

Evaluation of the effectiveness of preventive nursing measures for pressure injuries in patients in the neurology intensive care unit

BACKGROUND

Patients in neurology intensive care units (ICU) are prone to pressure injuries (PU) due to factors such as severe illness, long-term bed rest, and physiological dysfunction. PU not only causes pain and complications to patients, but also increases medical burden, prolongs hospitalization time, and affects the recovery process.

AIM

To evaluate and optimize the effectiveness of pressure injury prevention nursing measures in neurology ICU patients.

METHODS

A retrospective study was conducted, and 60 patients who were admitted to the ICU of the Department of Neurology were selected and divided into an observation group and a control group according to the order of admission, with 30 people in each group. The observation group implemented pressure injury prevention and nursing measures, while the control group adopted routine care.

RESULTS

Comparison between observation and control groups following pressure injury prevention nursing intervention revealed significantly lower incidence rates in the observation group compared to the control group at 48 h (8.3% vs 26.7%), 7 d (16.7% vs 43.3%), and 14 d (20.0% vs 50.0%). This suggests a substantial reduction in pressure injury incidence in the observation group, with the gap widening over time. Additionally, patients in the observation group exhibited quicker recovery, with a shorter average time to get out of bed (48 h vs 72 h) and a shorter average length of stay (12 d vs 15 d) compared to the control group. Furthermore, post-intervention, patients in the observation group reported significantly improved quality of life scores, including higher scores in body satisfaction, feeling and function, and comfort (both psychological and physiological), indicating enhanced overall well-being and comfort following the implementation of pressure injury prevention nursing measures.

CONCLUSION

Implementing pressure injury preventive care measures for neurology ICU patients will have better results.

The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta-analysis

BACKGROUND

Numerous interventions for pressure injury prevention have been developed, including care bundles.

OBJECTIVE

To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients.

DATA SOURCES

The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023).

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded.

PARTICIPANTS AND INTERVENTIONS

Bundles with ≥3 components directed towards patients and implemented in ≥2 hospital services were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42023423058.

TWEETABLE ABSTRACT

Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low.

Association between clinical characteristics of patients with pressure ulcer in the COVID-19 pandemic

OBJECTIVE

To analyze the associations between the clinical characteristics of patients hospitalized with pressure injuries (PI) during the COVID-19 pandemic.

METHOD

Cross-sectional study of 237 PI notifications in a hospital in southern Brazil. Collection took place in 2021 in an institutional management program, with interlocution to the patient's medical record. Analysis using descriptive statistics, Student's t-test, Pearson's chi-square and Wilcoxon.

RESULTS

The mean age was 59.4±14.4 years, with 59.7% male, 74.7% diagnosed with COVID-19. High risk (57.8%), stage 2 (80.2%), sacral region, intergluteal/gluteal region (73.0%) were predominant and death was the prevalent outcome (51.1%), with a median of 9.5 (0-217) days after notification. There was no association of death with diabetes, systemic arterial hypertension, smoking and reason for hospitalization.

CONCLUSION

The association between the clinical characteristics of hospitalized patients with pressure injuries reflects the systemic inflammation of patients affected by COVID-19.

Pressure ulcers during the COVID-19 pandemic in intensive care:A multicenter cohort study

AIM

The objective of the present study is twofold: to describe the prevalence and incidence of pressure ulcers (PUs) among ICU patients during the COVID-19 pandemic, and to identify the risk factors associated with the development of PUs in this cohort of ICU patients.

MATERIALS AND METHODS

Retrospective cohort study of adult critical care patients admitted in two general ICUs of two different countries (Sweden and Portugal) between March 1st, 2020, and April 30th, 2021, through the analysis of the electronic health record database. The prevalence and incidence were calculated, and a multivariate logistic-regression model was used to calculate odds ratios (ORs), of possible risk factors of PU development.

RESULTS

The sample consisted of 1717 patients. The overall prevalence of PU was 15.3 %, and the incidence of ICU-acquired PUs was 14.1 %. Most of the pressure ulcers documented in this study were at the anterior part of the body (45.35 %) and regarding classification, Category 2 (38.40 %) and Category 3 (22.71 %) pressure ulcers together accounted for over fifty percent of the cases recorded. In the multivariate logistic regression model for PU, age, having COVID-19 (OR = 1.58, 95 % CI: 1.20-2.09), use of mechanical ventilation (OR = 1.49, 95 % CI: 1.13 = 1.97), use of vasopressors (OR = 1.31, 95 % CI: 1.00-1.70), having a Braden risk score ≤16 at admission (OR = 1.63; 95 % CI: 1.04-2.56), and length of stay (LOS) (OR = 1.43, 95 % CI 1.03-2.00 if LOS 90-260 h, OR = 2.34, 95 % CI: 1.63-3.35 if LOS >260 h) were associated with the likelihood of developing an ICU-acquired PUs.

CONCLUSION

When adjusted for covariates patients with COVID-19 had a higher risk for PU development during the ICU stay compared to patients without COVID-19. Health care personnel in ICU may consider incorporating COVID-19, age, use of mechanical ventilation, vasopressors and estimated LOS in addition to a comprehensive risk assessment including both a risk score and clinical assessment.

The occurrence of pressure injuries and related risk factors in patients undergoing extracorporeal membrane oxygenation for respiratory failure: A retrospective single centre study

INTRODUCTION

Limited data is available regarding the incidence of pressure injuries in patients who have undergone Extracorporeal Membrane Oxygenation (ECMO), a life-saving technique that provides respiratory support for hypoxemia that does not respond to conventional treatment.

AIM

To assess the incidence of pressure injuries and identify the risk factors in Acute Respiratory Distress Syndrome patients receiving ECMO.

METHODS

A retrospective observational study utilizing prospectively collected data was performed in an Italian intensive care unit, between 1 January 2012 and 30 April 2022 enrolling all consecutive patients with Acute Respiratory Distress Syndrome who underwent ECMO.

RESULTS

One hundred patients were included in this study. 67 patients (67%) developed pressure injuries during their intensive care unit stay, with a median of 2 (1-3) sites affected. The subgroup of patients with pressure injuries was more hypoxic before ECMO implementation, received more frequent continuous renal replacement therapy and prone positioning, and showed prolonged ECMO duration, intensive care unit and hospital length of stay compared to patients without pressure injuries. The logistic model demonstrated an independent association between the pO2/FiO2 ratio prior to ECMO initiation, the utilization of the prone positioning during ECMO, and the occurrence of pressure injuries.

CONCLUSIONS

The incidence of pressure injuries was elevated in patients with Adult Respiratory Distress Syndrome who received ECMO. The development of pressure injuries was found to be independently associated with hypoxemia before ECMO initiation and the utilization of prone positioning during ECMO.

IMPLICATIONS FOR CLINICAL PRACTICE

Patients who require ECMO for respiratory failure are at a high risk of developing pressure injuries. To ensure optimal outcomes during ECMO implementation and treatment, it is vital to implement preventive measures and to closely monitor skin health in at-risk areas.

The Changing Prevalence of Pressure Injury among Ontarians with SCI/D at Rehabilitation Admission: Opportunities for Improvement

BACKGROUND

Despite preventability, 20-50% of patients with acute spinal cord injury/disease (SCI/D) develop hospital-acquired pressure injuries (PIs). The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) aimed to mitigate PI risk through patient-reported daily skin checks alongside usual care.

METHODS

This quality improvement initiative utilized an interrupted time series design, encompassing adults ≥ 18 years admitted for inpatient rehabilitation across five Ontario sites from 2020 to 2023. Patient demographics, etiology, and impairment data were obtained from a national registry, while participating sites gathered data on PI onset, location, and severity. Run charts depicted temporal trends, and statistical analyses, including chi-square and logistic regression, compared patients with and without PIs.

RESULTS

Data from 1767 discharged SCI/D patients revealed that 26% had ≥1 PI, with 59% being prevalent and 41% incident. Most severe PIs (stages III and IV and unstageable) were acquired prior to admission. Process indicator fidelity was reasonable at 68%. Patients with PIs experienced longer hospital stays, lower Functional Independence Measure (FIM) changes, and FIM efficiency during rehabilitation.

CONCLUSIONS

PI prevalence is increasing, particularly sacral injuries at admission, while incident cases have decreased since 2021 due to regular skin checks. This trend calls for proactive health system interventions to reduce costs and improve patient outcomes.

Pressure injury treatment by intermittent electrical stimulation (PROTECT-2): protocol for a multicenter randomized clinical trial

BACKGROUND

Pressure ulcers account for a substantial fraction of hospital-acquired pathology, with consequent morbidity and economic cost. Treatments are largely focused on preventing further injury, whereas interventions that facilitate healing remain limited. Intermittent electrical stimulation (IES) increases local blood flow and redistributes pressure from muscle-bone interfaces, thus potentially reducing ulcer progression and facilitating healing.

METHODS

The Pressure Injury Treatment by Intermittent Electrical Stimulation (PROTECT-2) trial will be a parallel-arm multicenter randomized trial to test the hypothesis that IES combined with routine care reduces sacral and ischial pressure injury over time compared to routine care alone. We plan to enroll 548 patients across various centers. Hospitalized patients with stage 1 or stage 2 sacral or ischial pressure injuries will be randomized to IES and routine care or routine care alone. Wound stage will be followed until death, discharge, or the development of an exclusion criteria for up to 3 months. The primary endpoint will be pressure injury score measured over time.

DISCUSSION

Sacral and ischial pressure injuries present a burden to hospitalized patients with both clinical and economic consequences. The PROTECT-2 trial will evaluate whether IES is an effective intervention and thus reduces progression of stage 1 and stage 2 sacral and ischial pressure injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05085288 Registered October 20, 2021.

Implementable Prediction of Pressure Injuries in Hospitalized Adults: Model Development and Validation

Background

Numerous pressure injury prediction models have been developed using electronic health record data, yet hospital-acquired pressure injuries (HAPIs) are increasing, which demonstrates the critical challenge of implementing these models in routine care.

Objective

To help bridge the gap between development and implementation, we sought to create a model that was feasible, broadly applicable, dynamic, actionable, and rigorously validated and then compare its performance to usual care (ie, the Braden scale).

Methods

We extracted electronic health record data from 197,991 adult hospital admissions with 51 candidate features. For risk prediction and feature selection, we used logistic regression with a least absolute shrinkage and selection operator (LASSO) approach. To compare the model with usual care, we used the area under the receiver operating curve (AUC), Brier score, slope, intercept, and integrated calibration index. The model was validated using a temporally staggered cohort.

Results

A total of 5458 HAPIs were identified between January 2018 and July 2022. We determined 22 features were necessary to achieve a parsimonious and highly accurate model. The top 5 features included tracheostomy, edema, central line, first albumin measure, and age. Our model achieved higher discrimination than the Braden scale (AUC 0.897, 95% CI 0.893-0.901 vs AUC 0.798, 95% CI 0.791-0.803).

Conclusions

We developed and validated an accurate prediction model for HAPIs that surpassed the standard-of-care risk assessment and fulfilled necessary elements for implementation. Future work includes a pragmatic randomized trial to assess whether our model improves patient outcomes.

The frequency of pressure injury in level 3 intensive care units and determination of risk factors: A cross-sectional study

AIM

This study was carried out to determine the prevalence of pressure injury and risk factors in patients hospitalized in a university hospital's level 3 intensive care unit.

DESIGN

It is a descriptive, prospective, observational type study.

METHOD

The sample of the study consisted of 176 patients aged 18 and over who were admitted to the intensive care units of a University Hospital for at least 24 h. Patient Information Form and Braden Risk Assessment Scale, Glasgow Coma Scale were used to collect data. IBM SPSS Statistics 20 program was used to analyze the data.

RESULTS

Presence of chronic disease in the development of pressure injury (22.7%), high-risk patients according to the Glasgow Coma Scale (21%), high-risk patients according to the Braden Risk Assessment Scale (84.2%), low hemoglobin (31%), low albumin levels (32.4%) and duration of stay in the intensive care unit until the day of evaluation were found to be independent risk factors (p < 0.05). The prevalence of pressure injury was determined to be 32.4%, and the rate of pressure injury due to medical devices was 7.4%.

CONCLUSION

Pressure injuries are still common in adult intensive care patients. In terms of patient safety, it is important to give more space to care standards and awareness-raising research and training to prevent pressure injuries.

Heel skin microclimate control: Secondary analysis of a self-controlled randomized clinical trial

OBJECTIVE

this study was undertaken to evaluate the efficacy of multilayer polyurethane foam with silicone (MPF) compared to transparent polyurethane film (TPF) dressings in the control of heel skin microclimate (temperature and moisture) of hospitalized patients undergoing elective surgeries.

METHOD

the study took of a secondary analysis of a randomized self-controlled trial, involving patients undergoing elective surgical procedure of cardiac and gastrointestinal specialties in a university hospital in southern Brazil, from March 2019 to February 2020. Patients served as their own control, with their heels randomly allocated to either TPF (control) or MPF (intervention). Skin temperature was measured using a digital infrared thermometer; and moisture determined through capacitance, at the beginning and end of surgery. The study was registered in the Brazilian Registry of Clinical Trials: RBR-5GKNG5.

RESULTS

significant difference in the microclimate variables were observed when the groups (intervention and control) and the timepoint of measurement (beginning and end of surgery) were compared. When assessing temperature, an increase (+3.3 °C) was observed with TPF and a decrease (-7.4 °C) was recorded with MPF. Regarding skin moisture, an increase in moisture (+14.6 AU) was recorded with TPF and a slight decrease (-0.3 AU) with MPF.

CONCLUSIONS

The findings of this study suggest that MPF is more effective than TPF in controlling skin microclimate (temperature and moisture) in heels skin of hospitalized patients undergoing elective surgeries. However, this control should be better investigated in other studies.

Dose-response relationships between body-mass index and pressure injuries occurrence in hospitalized patients: A multi-center prospective study

BACKGROUND

Pressure injuries (PIs) are one of the leading potentially preventable hospital-acquired complications associated with prolonged hospital length, poor quality of life and financial burden. The relationship between body mass index (BMI) and PIs occurrence is controversial.

OBJECTIVE

The aim of this study was to further examine relationships between BMI and PIs occurrence in hospitalized patients.

DESIGN

A multi-center prospective study.

SETTING

39 hospitals located in northwest China from April 2021 to July 2023.

PARTICIPANTS

175,960 hospitalized patients aged over 18 years were enrolled, and 170,800 patients were included in the final analysis.

METHODS

BMI and clinical characteristics were assessed at baseline. PIs assessment were performed by trained nurses, with data recorded for the presence, the location and stage of each PI. For staging PIs, the National Pressure Ulcer Advisory Panel（NPUAP） staging system were used. The multivariate logistic regressions analysis and restricted cubic splines (RCS) models were used to explore associations between BMI and PIs, adjusting for potential confounders.

RESULTS

Of 175,960 participants, 5160 were excluded from analyses. The multivariate logistic regression model identified a positive relationship between under-weight BMI and risk of PIs occurrence (OR = 1.60, 95% CI:1.18-2.17). We also found U shaped association between BMI and PIs occurrence (non-linear P < 0.001). BMI less than 23 kg/m2 significantly increased risk of PIs, and there was a tendency to increase risk of PIs at BMI higher than 30 kg/m2. We stratified participants by sex to further investigate their association and found the risk of PIs increases substantially in women at BMI below 17 kg/m2 and in men at BMI below 23 kg/m2.

CONCLUSIONS

The present study indicated that there was an approximate U shaped relationship between BMI and PIs occurrence, and this association was potentially different between men and women.

Comparison of the Predictive Validity of Norton and Braden Scales in Determining the Risk of Pressure Injury in Elderly Patients

AIM

To compare the reliability and predictive validity of Norton and Braden scales in determining the risk of pressure injury in elderly patients.

DESIGN

This research used a comparative design. One hundred thirty elderly patients participated in the study.

METHODS

The daily pressure injury risk of participants was evaluated by a researcher using both the Norton and Braden scales in a consecutive manner.

RESULTS

The mean age of patients was 75.1 ± 8.5 years, and that for those without and with pressure injury development was 75.0 ± 8.3 years and 76.1 ± 9.7 years (P < .001), respectively. The reliability coefficients of the Norton and Braden scales were .82 and .89, respectively. The sensitivity, specificity, and positive and negative predictive values of the Norton Scale were 100%, 40.7%, 20.2%, and 100%, and those of the Braden Scale were 100%, 32.7%, 18.3%, and 100%, respectively.

CONCLUSIONS

The reliability of both scales for elderly patients was found to be high, and their ability to differentiate patients at risk was comparable. However, both scales had low specificity. Further research is needed to develop scales that have higher predictive validity for the elderly population, taking into account other risk factors that influence total scale scores.

Knowledge, attitude, and practice of critical care nurses and their influence on acute skin failure patients in China: A multicenter cross-sectional study

AIM

Acute skin failure (ASF) can happen in critically ill patients. Therefore, adequate knowledge and skills regarding ASF are essential to manage this disorder. The aim of this work was to investigate the nurses' knowledge, attitude, and practice (KAP) regarding ASF patients and to analyze its influencing factors in the intensive care unit.

METHODS

A multicenter cross-sectional study was performed in 10 tertiary hospitals in March 2022. Eligible nurses received a survey with a self-designed questionnaire about their KAP regarding ASF, which included three dimensions and a maximum score of 120. A higher score corresponded to better KAP.

RESULTS

A total of 255 nurses participated in this study. The mean KAP score was 75.6 ± 16.9. The mean scores of the knowledge, attitude, and practice dimensions were 26.2 ± 10.6, 38.2 ± 6.1, and 11.3 ± 4.3, respectively. The dimensions were ranked according to score (from low to high) as follows: knowledge (2.6 ± 1.1), practice (2.8 ± 1.1), and attitude (3.8 ± 0.6). Multivariate linear regression analysis showed that more training sessions and an advanced professional title were associated with higher KAP scores.

CONCLUSIONS

The overall KAP score on ASF was low in nurses. Nurses had a positive attitude towards ASF, but their knowledge and practice required significant improvement. Those who had received more training and held a more advanced professional title exhibited higher KAP scores regarding ASF. Therefore, nurse managers should establish a relevant knowledge training system, strengthen relevant training, and improve nursing practices for ASF in order to achieve a high level of KAP in nurses who treat ASF patients.

Incidence, characteristics, and associated factors of pressure injuries acquired in intensive care units over a 12-month period: A secondary analysis of a quality improvement project

OBJECTIVES

To determine the 12-month cumulative incidence, characteristics, and associated factors of pressure injuries acquired in Intensive Care Units.

SETTING

Four intensive care units in a Norwegian University Hospital.

RESEARCH METHODOLOGY

A prospective observational cohort study using data from daily skin inspections during a quality improvement project. We used descriptive statistics and logistic regression. Variables associated with the development of intensive care unit-acquired pressure injuries are presented with odds ratios (OR), and 95% confidence intervals.

RESULTS

The 12-month cumulative incidence of patients (N = 594) developing intensive care unit-acquired pressure injuries was 29 % (172/594) for all categories and 16 % (95/594) when excluding category I pressure injuries (no skin loss). Cumulative incidence for patients acquiring medical device-related pressure injuries was 15 % (91/594) and 11 % (64/594) for category II or worse. Compression stockings (n = 51) and nasogastric tubes (n = 22) were the most frequent documented medical devices related to pressure injuries. Development of pressure injuries category II or worse was significantly associated with vasoactive drug infusions (OR 11.84, 95 % CI [1.59; 88.13]) and longer intensive care unit length of stay (OR 1.06, 95 % CI [1.04; 1.08]).

CONCLUSION

The 12-month cumulative incidence of intensive care unit-acquired pressure injuries was relatively high when category I pressure injuries were included, but comparable to other studies when category I was excluded. Some medical device-related pressure injuries were surprisingly frequent, and these may be prevented. However, associated factors of developing pressure injuries were present and deemed non-modifiable.

IMPLICATIONS FOR CLINICAL PRACTICE

Awareness about pressure injury prevention is needed in the intensive care unit considering high incidences. Nurses can detect category I pressure injuries early, which may be reversed. Our findings show several factors that clinicians can control to reduce the risk of pressure injuries in the intensive care unit.

Exploring body morphology, sacral skin microclimate and pressure injury development and risk among patients admitted to an intensive care unit: A prospective, observational study

OBJECTIVE

To determine the association between body morphology, sacral skin microclimate and their impact on the development and risk of pressure injuries among patients in an intensive care unit.

METHODOLOGY

A prospective observational exploratory study was conducted over 30 weeks. Repeat study observations occurred multiple times a week for 28 days or until discharge. Participant inclusion criteria were ≥ 18 years of age, expected intensive care length of stay > 24 h and intact skin over the sacrum region.

SETTING

The study was conducted in a 36-bed intensive care unit of a major metropolitan public hospital in Queensland, Australia.

OUTCOME MEASURES

Pressure injuries were staged and independently verified according to the international pressure injury classification system. Pressure injury risk was determined by the Braden scale score and subepidermal oedema, using a subepidermal moisture scanner at the sacrum.

RESULTS

Of the 93 participants recruited, an inverted triangle body shape (p =.049), a BMI > 25 kg/m2 (p =.008), a standard foam mattress type (p =.017) and increased length of stay (p <.001) were associated with an increased pressure injury risk according to subepidermal oedema. Participants with increased sacral skin temperature (p <.001), mechanical ventilation (p <.001), vasoactive drugs administered (p =.003), increased sequential organ failure assessment score (p =.047), neurovascular diagnosis (p =.031) and increased length of stay (p =.027) were associated with increased pressure injury risk according to the Braden scale score.

CONCLUSION

Body morphology and skin microclimate are associated with pressure injury risk during critical illness.

IMPLICATIONS FOR CLINICAL PRACTICE

Subepidermal oedema was associated with a patient's shape, body mass index and mattress type, factors that directly influence the pressure loading and the skin, whereas the Braden scale was associated with sacral temperature and clinical measures of critical illness. Consideration of body morphology and skin microclimate in pressure injury risk assessment could lead to more specific prevention strategies targeting high risk patients.

Determinants of pressure injury development in patients with COVID-19

OBJECTIVE

Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19.

METHOD

A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement.

RESULTS

A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage.

CONCLUSION

PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

The Impact of COVID-19 on Rates of Pressure Injuries Among Hospitalized Patients across the US

OBJECTIVE

To determine the impact of the COVID-19 pandemic on hospital-acquired pressure injury (HAPI) rates and composition of HAPI stages among hospitalized patients across the US.

METHODS

Using encounter-level data from a nationwide healthcare insurance claims database, the authors conducted a retrospective cohort study and an interrupted time-series analysis to determine HAPI rates among hospitalized patients within 90 days of admission before (January 2018 to February 2020) and after (March 2020 to December 2020) the onset of the COVID-19 pandemic. Of 3,418,438 adult patients assessed for inclusion in the study, 1,750,494 met the inclusion criteria. Outcomes measured included the presence of a HAPI within 90 days of admission and HAPI stage based on the International Classification of Diseases, 10th Revision diagnosis codes.

RESULTS

The authors identified HAPIs in 59,175 episodes of care, representing 59,019 unique patients and corresponding to an overall HAPI rate of 2.65%. Baseline characteristics did not vary significantly across the two time periods. Further, HAPI rates were consistent across the time periods analyzed with no significant differences in rates following the onset of the pandemic (P = .303). Composition of HAPI stages remained consistent across the pandemic (unspecified, stages 1-4, Ps = .62, .80, .22, .23, and .52, respectively) except for a significant decrease in unstageable/deep tissue pressure injuries (-0.088%, P = .0134).

CONCLUSIONS

Although hospital resources were strained at the peak of the COVID-19 pandemic, no differences were identified in HAPI rates among the study's cohort of privately insured patients.

Nomogram model on estimating the risk of pressure injuries for hospitalized patients in the intensive care unit

OBJECTIVES

This study aimed to build and validate a nomogram model to estimate the risk of pressure injuries in intensive care unit patients.

DESIGN

Multicenter prospective cohort study.

SETTING

33 tertiary hospitals in the Gansu Province, China.

MEASUREMENTS AND MAIN RESULTS

This study included 6420 patients between April 2021 to October 2022 from an information platform of pressure injury risk management called the "Long Hu Hui." Univariate and multivariate logistic regression analyses identified pressure injury risk factors to be included in the nomogram. The resulting nomogram was tested for calibration discrimination, and clinical usefulness. Of the included patients, 77 developed pressure injuries, representing an incidence rate of 1.2 %. Analysis of binary logistic regression revealed that the estimation nomogram included weight loss greater than 5 kg in the last three months, pneumotomy cannula, thoracic catheter, isoproterenol, norepinephrine, abnormal skin color, ruptured erythema, stroke, increased body temperature and nonspecific patients (specific patients include paralysis, unconsciousness, dementia, forced body position). The area under the receiver operating characteristic curve for the training cohort was 0.806 (95 % CI 0.755-0.857), and the AUC of the text cohort was 0.737 (95 % CI 0.574-0.901). The model has excellent calibration in both the training cohort (H-L test: χ2 = 6.34, P = 0.61) and the text cohort (H-L test: χ2 = 4.50, P = 0.81). Furthermore, the decision curve analysis revealed the preferred net benefit and the threshold probability in the estimation nomogram.

CONCLUSIONS

The nomogram model accurately estimated the risk of pressure injuries among intensive care patients, it should be used to inform risk assessment and facilitate early intervention strategies in future practice.

IMPLICATIONS FOR CLINICAL PRACTICE

The nomogram allows intensive care providers to dynamically assess the patient's risk of pressure injuries and to implement more targeted interventions accordingly.

The practice and facilitators of, and barriers to, implementing individualized repositioning frequency: A national cross-sectional survey of critical care nurses

AIMS

To understand the clinical status of implementing individualized repositioning frequency-and its barriers and facilitators-among critical care nurses in China, in view of developing targeted intervention strategies and improving guideline implementation.

DESIGN

A cross-sectional survey.

METHODS

A self-report questionnaire was developed with reference to the Theoretical Domains Framework and administered to critical care nurses in 15 hospitals across eastern, southern, western, northern, and central geographical areas of China from 20 February 2023 to 16 March 2023. Data were collected for personal demographics, clinical practice status, and from Likert-type responses about barriers to and facilitators of implementing individualized repositioning frequency.

RESULTS

In total, 574 effective questionnaires were collected. Only 3.8 % of respondents reported that their hospital/ward uses an individualized repositioning frequency rule. Six facilitator domains identified were: social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; and intentions. Seven barrier domains were: knowledge; skills; goals; memory, attention and decision processes; environmental context and resources; social influences; and behavioral regulation. Inferential analysis showed that critical care nurses who had higher degrees, more years of work, more environmental support, and more nursing experience were prone to being more positive in response to the implementation of individualized repositioning frequency.

CONCLUSION

The clinical practice status of implementing individualized repositioning frequency among critical care nurses in China is unsatisfactory. Implementation is essential but complex and is influenced by several factors. Theory-based suggestions for improving this situation are provided on the basis of identified barriers.

Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study

BACKGROUND

The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications.

AIM

To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO.

STUDY DESIGN

This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model.

RESULTS

In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532).

CONCLUSIONS

Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO.

RELEVANCE TO CLINICAL PRACTICE

The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

Incidence and risk factors of pressure injuries in critically ill patients with COVID-19

OBJECTIVE

to analyze pressure injury (PI) incidence and risk factors in patients with COVID-19 admitted to an Intensive Care Unit and characterize the identified PIs.

METHOD

a retrospective cohort study, consisting of 668 patients, carried out between March 2020 and February 2021. Clinical/demographic and PI variables were collected from medical records and electronic database. Data were analyzed using descriptive and inferential statistics. Logistic regression was performed to analyze risk factors for PI.

RESULTS

PI incidence was 30.2% (n=202), with the majority located in the sacral region (52.9%) and in stage 1 (39%). Risk factors were age (p<0.001), Diabetes Mellitus (p=0.005), length of stay (p<0.001), immunosuppression (p=0.034), nutritional risk (p=0.015) and mechanical ventilation (p<0.001).

CONCLUSION

PI incidence in critically ill patients with COVID-19 was high.

Prevalence and incidence of pressure injuries among older people living in nursing homes: A systematic review and meta-analysis

BACKGROUND

Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population.

OBJECTIVES

To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s).

DESIGN

Systematic review and meta-analysis.

SETTING(S)

Nursing homes, aged care, or long-term care facilities.

PARTICIPANTS

Older people, 60 years and older.

METHODS

Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I2 statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression.

RESULTS

3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6-13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2-8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5-26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4-13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection.

CONCLUSION

The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries.

REGISTRATION NUMBER

PROSPERO CRD42022328367.

TWEETABLE ABSTRACT

Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals.

Critical care nurses' knowledge and attitudes toward pressure injury prevention: A pre and post intervention study

OBJECTIVE

To explore nurses' knowledge and attitudes towards pressure injury prevention before and after implementing an educational intervention.

DESIGN/METHOD

A pre-and post-intervention study. Pre-intervention data collection involved administering an instrument, including demographic information, the Pressure Ulcer Knowledge Assessment Tool version 2, and the Attitudes towards Pressure Ulcer Prevention instruments. Following the analysis of pre-intervention data, an educational intervention was implemented. Post-intervention data were collected using the same instrument.

SETTING

Intensive care units at three Saudi Arabian hospitals.

MAIN OUTCOME MEASURES

Nurses' knowledge and attitudes towards pressure injury prevention.

RESULTS

The pre-intervention phase included 190 participants, and the post-intervention phase included 195 participants. Participants completed a paper-based survey at two different time points between June 2021 and March 2022. The mean pre-intervention scores for nurses' knowledge and attitudes towards pressure injury prevention were 43.22% and 74.77%, respectively. Following the educational intervention, the knowledge and attitude scores increased significantly to 51.22% and 79.02%, respectively. Higher knowledge of pressure injury prevention was positively associated with positive attitudes towards prevention practices. Age, clinical nursing experience, and experience in intensive care units were identified as factors correlated with knowledge of pressure injury prevention. A Bachelor's qualification or higher predicted better knowledge and attitudes towards pressure injury prevention.

CONCLUSIONS

Nurses' knowledge and attitudes towards pressure injury prevention greatly improved following tailored, evidence-based education. The educational intervention featured multiple on-site bedside discussions, case studies, small-group presentations, and the provision of printed resources.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses' knowledge and attitudes towards pressure injury prevention should be examined, and education provided to ensure evidence-based prevention practices are implemented. Tailored small-group education sessions delivered conveniently could be an effective approach. Efforts should focus on attracting and retaining experienced, highly qualified nurses to ensure the adoption of evidence-based prevention practices.

The theory and practice of pressure ulcer/injury risk assessment: a critical discussion

Pressure ulcer/injury (PU) risk assessment is widely considered an essential component in clinical practice. It is a complex and broad concept that includes different approaches, such as clinical judgement, using standardised risk assessment instruments, skin assessments, or using devices to measure skin or tissue properties. A distinction between PU risk assessment and early detection is important. PU risk measures the individual's susceptibility to developing a PU under a specific exposure (primary prevention), and early detection includes the assessment of early (sub)clinical signs and symptoms to prevent progression and to support healing (secondary prevention). PU risk is measured using prognostic/risk factors or prognostic models. Every risk estimate is a probability statement containing varying degrees of uncertainty. It therefore follows that every clinical decision based on risk estimates also contains uncertainty. PU risk assessment and prevention is a complex intervention, where delivery contains several interacting components. There is a huge body of evidence indicating that risk assessment and its outcomes, the selection of preventive interventions and PU incidence are not well connected. Methods for prognostic model development and testing in PU risk research must be improved and follow state-of-the-art methodological standards. Despite these challenges, we do have substantial knowledge about PU risk factors that helps us to make better clinical decisions. An important next step in the development of PU risk prediction might be the combination of clinical and other predictors for more individualised care. Any prognostic test or procedure must lead to better prevention at an acceptable cost.

The paradox of obesity in pressure ulcers of critically ill patients

The relationship between body mass index and pressure ulcers in critically ill patients is controversial. We aimed to investigate the association between body mass index and pressure ulcers by analysing data from the Medical Information Mart for Intensive Care IV (version 2.0) database. Eligible data (21 835 cases) were extracted from the database (2008-2019). The association between body mass index and pressure ulcers in critically ill patients was investigated by adjusting multivariate trend analysis, restricted cubic spline analysis, and segmented linear models. Subgroup analyses and sensitivity analyses were used to ensure the stability of the results. Trend analysis and restricted cubic spline analysis showed an approximate U-shaped correlation between body mass index and the occurrence of pressure ulcers in critically ill patients, with the risk of pressure ulcers decreasing rapidly with increasing body mass index (8.6% decrease per unit) after adjusting for relevant factors; the trend reached its minimum at a body mass index of 27.5 kg/m2, followed by a slow increase in the risk of pressure ulcers with increasing body mass index (1.4% increase per unit). Among the subgroups, the highest overall risk of pressure ulcers and the risk of severe pressure ulcers were significantly higher in the underweight group than in the other subgroups, and the risk associated with the overweight group was the lowest. There is a U-shaped association between body mass index and pressure ulcers in critically ill patients, and being underweight and obese both increase the risk of pressure ulcers. The risk is highest among underweight patients and lowest among overweight patients (but not patients of normal weight), necessitating targeted prevention strategies for critically ill patients with different body mass indexes.

Modelling the cost-effectiveness of subepidermal moisture measurement as part of a process of assessment and intervention to prevent hospital-acquired pressure ulcers

Skin tissue assessment is traditionally used to identify early signs of pressure damage from changes observed at the skin surface. However, the early onset of tissue damage induced by pressure and shear forces is likely to be on soft tissues beneath the surface of the skin. Subepidermal moisture (SEM) is a biophysical marker for the detection of early and deep pressure-induced tissue damage. Measurement of SEM can detect early pressure ulcers up to 5 days before visible skin changes occur. The aim of this study was to evaluate the cost-effectiveness of SEM measurement compared with visual skin assessment (VSA). A decision-tree model was developed. Outcomes are the incidence of hospital-acquired pressure ulcers, quality-adjusted life-years (QALYs) and costs to the UK National Health Service. Costs are at 2020/21 prices. The effects of parameter uncertainty are tested in univariate and probabilistic sensitivity analysis. In a representative NHS acute hospital, the incremental cost of SEM assessment as an adjunct to VSA is -£8.99 per admission, and SEM assessment is expected to reduce the incidence of hospital-acquired pressure ulcers by 21.1%, reduce NHS costs and lead to a gain of 3.634 QALYs. The probability of cost-effectiveness at a threshold of £30 000 per quality-adjusted life year is 61.84%. Pathways that include SEM assessment make it possible to implement early and anatomy-specific interventions which have the potential to improve the effectiveness of pressure ulcer prevention and reduce healthcare costs.

The PRINCOVID Retrospective Study: A Predictive Model of Pressure Injuries for Critical COVID-19 Patients

OBJECTIVE

The aim of the study is to characterize pressure injuries, identify risk factors, and develop a predictive model for pressure injuries at intensive care unit admission for critical COVID-19 patients.

DESIGN

This study was a retrospective analysis of a consecutive sample of patients admitted to intensive care unit between May 2020 and September 2021. Inclusion criteria encompassed the diagnosis of acute respiratory distress syndrome due to SARS-CoV-2, requiring invasive mechanical ventilation more than 48 hrs. The following predictors were evaluated: sociodemographic characteristics, comorbidities, as well as clinical and laboratory findings at intensive care unit admission. The primary outcome was the presence of pressure injuries.

RESULTS

Two hundred five patients were included, mostly males (73%) with a mean age of 62 yrs. Pressure injury prevalence was 58%. On multivariable analysis, male sex, hypertension, hemoglobin, and albumin at intensive care unit admission were independently associated with pressure injuries, constituting the PRINCOVID model. The model reached an area under the receiver operating characteristic curve of 0.71, surpassing the Braden scale ( P = 0.0015). The PRINCOVID score ranges from 0 to 15, with two risk groups: "at risk"(≤7 points) and "high risk"(>7 points).

CONCLUSIONS

This study proposes PRINCOVID as a multivariable model for developing pressure injuries in critical COVID-19 patients. Based on four parameters (sex, hypertension, hemoglobin, and albumin at intensive care unit admission), this model fairly predicts the development of pressure injuries. The PRINCOVID score allows patients' classification into two groups, facilitating early identification of high-risk patients.

Pressure Injury in Intensive Care Unit: prevalence and associated factors in patients with COVID-19

OBJECTIVE

To determine the frequency of pressure injuries and identify associated risk factors in patients affected by COVID-19 admitted to an intensive care unit.

METHOD

Cross-sectional, retrospective study with a quantitative approach carried using a documentary research. The sample included 393 medical records that were in accordance with our inclusion criteria, selected from March 2020 to March 2021 in a hospital in the south of Brazil. Data were analyzed using descriptive statistics in the software Bioestat 5.

RESULTS

The prevalence of pressure injuries in COVID-19 patients was 42%, the risk factors associated with these injuries were hospitalization time, ventilation treatment, and staying in the prone position, all with a significance of p<0.05.

CONCLUSION

Patients with COVID-19 are subject to several unmodifiable factors that are determinant for the appearance of pressure injuries. Therefore, preventive measures should be rigorously applied to this population.

Negative pressure wound therapy for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, pressure sores, or pressure injuries, are localised damage to the skin and underlying soft tissue, usually caused by intense or long-term pressure, shear, or friction. Negative pressure wound therapy (NPWT) has been widely used in the treatment of pressure ulcers, but its effect needs to be further clarified. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To evaluate the effectiveness of NPWT for treating adult with pressure ulcers in any care setting.

SEARCH METHODS

On 13 January 2022, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase, and EBSCO CINAHL Plus. We also searched ClinicalTrials.gov and the WHO ICTRP Search Portal for ongoing and unpublished studies and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of adults with pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection, data extraction, risk of bias assessment using the Cochrane risk of bias tool, and the certainty of the evidence assessment using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. Any disagreement was resolved by discussion with a third review author.

MAIN RESULTS

This review included eight RCTs with a total of 327 randomised participants. Six of the eight included studies were deemed to be at a high risk of bias in one or more risk of bias domains, and evidence for all outcomes of interest was deemed to be of very low certainty. Most studies had small sample sizes (range: 12 to 96, median: 37 participants). Five studies compared NPWT with dressings, but only one study reported usable primary outcome data (complete wound healing and adverse events). This study had only 12 participants and there were very few events; only one participant was healed in the study (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.15 to 61.74, very low-certainly evidence). There was no evidence of a difference in the number of participants with adverse events in the NPWT group and the dressing group, but the evidence for this outcome was also assessed as very low certainty (RR 1.25, 95% CI 0.64 to 2.44, very low-certainty evidence). Changes in ulcer size, pressure ulcer severity, cost, and pressure ulcer scale for healing (PUSH) sores were also reported, but we were unable to draw conclusions due to the low certainly of the evidence. One study compared NPWT with a series of gel treatments, but this study provided no usable data. Another study compared NPWT with 'moist wound healing',  which did not report primary outcome data. Changes in ulcer size and cost were reported in this study, but we assessed the evidence as being of very low certainty; One study compared NPWT combined with internet-plus home care with standard care, but no primary outcome data were reported. Changes in ulcer size, pain, and dressing change times were reported, but we also assessed the evidence as being of very low certainty. None of the included studies reported time to complete healing, health-related quality of life, wound infection, or wound recurrence.

AUTHORS' CONCLUSIONS

The efficacy, safety, and acceptability of NPWT in treating pressure ulcers compared to usual care are uncertain due to the lack of key data on complete wound healing, adverse events, time to complete healing, and cost-effectiveness.  Compared with usual care, using NPWT may speed up the reduction of pressure ulcer size and severity of pressure ulcer, reduce pain, and dressing change times. Still, trials were small, poorly described, had short follow-up times, and with a high risk of bias; any conclusions drawn from the current evidence should be interpreted with considerable caution. In the future, high-quality research with large sample sizes and low risk of bias is still needed to further verify the efficacy, safety, and cost-effectiveness of NPWT in the treatment of pressure ulcers. Future researchers need to recognise the importance of complete and accurate reporting of clinically important outcomes such as the complete healing rate, healing time, and adverse events.

A case report of the treatment and care of decubitus ulcers in macaques with spinal cord injury

Decubitus ulcers are a common spinal cord injury (SCI) complication that puts patients' lives in danger and has emerged as a more prevalent issue in modern clinical rehabilitation and care. Decubitus ulcers in humans can currently be treated in a number of different ways, but there are fewer studies on how to treat and care for decubitus ulcers in macaques. To treat a 20-year-old adult male macaque monkey with SCI and decubitus ulcers after a quarter transection of the thoracic spinal cord, a number of scientific care procedures and pharmaceutical treatments, such as dietary changes and topical or intravenous administration of medication, were carried out and continuously monitored in real-time. In comparison to the untreated group, we observed a significant improvement in decubitus wound healing in the macaques. In this article, we provide a good protocol for decubitus ulcer care after SCI and suggest that future experimental animal modeling needs to focus on issues such as care for postoperative complications.