Pressure ulcers in ICU patients: Incidence and clinical and epidemiological features: A multicenter study in southern Brazil

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.

Aetiology, risk factors and treatment of typical and atypical pressure ulcers in patients with traumatic brain injury: A narrative review

Pressure ulcers are one of the leading complications in bedridden patients that result in multiple burdens on healthcare systems and patients (11 billion dollars/year). The prevalence of pressure ulcers in traumatic brain injury patients is 1.5-fold compared with the other bedridden patients. Moreover, critical traumatic brain injury patients who are admitted to the intensive care unit experience severe pressure ulcers and further complications. The motor/sensory disabilities and low supplementation and oxygenation to the pressured side were the main mechanisms of the typical pressure ulcers. Intellectual evaluation is the first essential step to prevent the development of pressure ulcers in high-risk patients. Till now, different scales, including Injury Scale Score and Braden Scale Score, have been provided to assess the pressure ulcer. Since low stages of pressure ulcers heal rapidly, traumatic brain injury patients require a periodical assessment to prevent further developments timely. Alongside different procedures provided to prevent and treat any pressure ulcer, traumatic brain injury patients required additional specific protections. For the first line, fast and efficient rehabilitation repairs motor/sensory disabilities and decreases the chance of pressure ulcer. Our review indicated that pressure ulcer in traumatic brain injury had several complex mechanisms that demand special care. Therefore, further studies are required to address these mechanisms and prevent their progression to typical and atypical pressure ulcers.

Validity and reliability of the italian-Neonatal skin risk assessment scale (i-NSRAS)

BACKGROUND

The skin of infants has important anatomical and physiological differences from that of children and adults. Because of skin immaturity, reduced mobility, neurological changes, and the need for medical devices, infants are at high risk for pressure injuries. Specific, validated tools are needed to assess the risk of pressure injuries in this population.

OBJECTIVES

To assess the psychometric properties of the Italian version of Neonatal Skin Risk Assessment Scale (construct validity, internal consistency and reliability).

METHOD

A cross-sectional descriptive study was conducted in the neonatal units of the two Italian hospitals. 200 infants were examined 3 times by 54 nurses to assess the risk of pressure injuries. Exploratory and confirmatory factor analysis were performed jointly to assess construct validity. Internal consistency was analyzed using McDonalds omega coefficient and Cronbach's alpha, while intra and interobserver agreement using Intraclass Correlation Coefficients (ICC).

RESULTS

Exploratory factor analysis confirmed a 2-factor model; the factor "duration and intensity of pressure" explained four subscales (mental state, mobility, activity and nutrition), while "skin immaturity" explained the subscales (general physical condition and skin moisture). Confirmatory factor analysis results indicated good model fits (X2/df = 0.84, p = 0.002, RMSEA = 0, NNFI = 1.01, NFI = 0.98 y CFI = 1 (M1 with MI). The italian-Neonatal Skin Risk Assessment Scale showed a good internal consistency, McDonalds omega coefficient and Cronbach's alpha both 0.86. An excellent intra and inter observer reliability was also observed, ICC 0.99 and 0.98 respectively.

CONCLUSION

The psychometric characteristics indicate that the italian-Neonatal Skin Risk Assessment Scale is useful, valid and reliable for measuring risk of pressure injuries in the neonatal population.

IMPLICATIONS FOR CLINICAL PRACTICE

This is the first valid and reliable newborn-specific scale that assesses the presence of medical devices. Its use could enable efficient management of preventive resources, early classification of newborns at risk and assignment of preventive interventions, facilitate the development of risk assessment protocols.

Vasoconstrictor Agent Administration as a Risk Factor for Pressure Injury Development in Intensive Care Unit Patients: A Systematic Review and Meta-Analysis

Significance: Pressure injury (PI) is a common critical presentation in intensive care units (ICU) and is an important clinical concern in critical care settings. Some developing data support the vasoconstrictor agent administration as a potential risk factor; however, synthesis of available evidence has not been completed. Recent Advances: Comprehensive tactics were employed to search electronic databases PubMed, Web of Science, and Ovid Embase for data on vasoconstrictor agent administration associated with PI in ICU patients. Extraction was limited to studies that matched the inclusion criteria. The pooled odds ratio and 95% confidence intervals (95% CI) were calculated for dichotomous outcomes. Critical Issues: Twenty-six studies were included, involving 50,192 patients who matched the selection criteria. Around 5.8% of patients (2,523/43,210) got PI in total. PI occurred in 10.9% (1,496/13,675) of the vasoconstrictor agent administration population and 3.5% (1,027/29,503) of the drug-free population. The pooled unadjusted odds ratio was 2.83 (95% CI = 2.21-3.64, p < 0.001). The adjusted odds ratio was 1.83 (95% CI = 1.26-2.68, p = 0.002). Subgroup analysis and meta-regression found that the risk of PI did not vary with research design, time of occurrence, patient age, or male proportion. Future Directions: Vasoconstrictor agent administration raised the risk of PI in critical care patients by nearly twofold. More emphasis should be placed on the timely prevention of PI in patients receiving vasoconstrictor agent administration in the ICU.

Knowledge, Attitude, and Practice of Skin Care Among Elderly Patients in Riyadh, Saudi Arabia

As people age, the likelihood that they will experience maladies of the skin increases. It is therefore important that older individuals possess the necessary knowledge and proper attitudes and practices regarding their skincare. The purpose of this study was to examine such knowledge, attitudes, and practices among older members of the Saudi Arabian population. The results of the study showed that among the majority of the participants, skincare practices could be considered insufficient and, surprisingly, elderly men undertake better skincare practices than women of this age category. It is recommended that more should be done to educate those within the older Saudi population regarding skin care practices.

Pressure ulcer incidence in critically ill patients: Role of body mass index, nutrition therapy, and other non-nutritional factors

OBJECTIVE

To assess the clinical and nutritional risk factors related to the occurrence of pressure ulcers (PUs) in patients admitted to an Intensive Care Unit (ICU).

METHODS

This is a cohort retrospective study, carried out by analyzing the medical records of patients admitted to the ICU of a hospital, containing information on sociodemographic, clinical, dietary, and anthropometric data, presence of mechanical ventilation, sedation, and use of noradrenaline. To verify the clinical and nutritional risk factors, multivariate Poisson's regression with robust variance was used to estimate the relative risk (RR) according to the explanatory variables.

RESULTS

A total of 130 patients were evaluated from January 1 to December 31, 2019. The incidence of PUs in the study population was 29.2%. In univariate analysis, male sex, suspended or enteral diet, use of mechanical ventilation, and sedatives had a significant association with the PUs (p < 0.05). However, when adjusted for potential confounders, only suspended diet remained associated with the PUs. Furthermore, in an analysis stratified by hospitalization time, it was observed that for each 1 kg/m² increase in body mass index, there is a 10% increased risk of PUs occurrence (RR: 1.10; 95%CI: 1.01-1.23).

CONCLUSION

Patients with suspended diet, diabetics, with longer-time hospitalization, and overweight have a higher risk of presenting pressure ulcers.

The Role of Cold Atmospheric Plasma in Wound Healing Processes in Critically Ill Patients

Critically ill patients are at risk of skin wounds, which reduce their quality of life, complicate their pharmacological regimens, and prolong their hospital stays in intensive care units (ICUs), while also increasing overall mortality and morbidity rates. Cold atmospheric plasma (CAP) has been proposed as a viable option for many biological and medical applications, given its capacity to reduce wound bacterial contamination and promote wound healing. The aim of this narrative review is to describe how CAP works and its operating mechanisms, as well as reporting its possible applications in critical care settings. The success of CAP in the treatment of wounds, in particular, bedsores or pressure sores, presents an innovative path in the prevention of nosocomial infections and an opportunity of reducing the negative implications of these diseases for the NHS. This narrative review of the literature was conducted following the 'Scale for the Assessment of Narrative Review Articles' (SANRA) methodology. Previous literature highlights three biological effects of plasma: inactivation of a wide range of microorganisms, including those that are multi-drug-resistant; increased cell proliferation and angiogenesis with a shorter period of plasma treatment; and apoptosis stimulation with a longer and more intensive treatment. CAP is effective in many areas of the medical field, with no significant adverse effects on healthy cells. However, its use can produce potentially serious side effects and should, therefore, be used under expert supervision and in appropriate doses.

Evaluation of the effect of fish oil in the prevention of pressure ulcers in patients admitted to the intensive care unit

Introduction

Today, the anti-inflammatory property of fish oil is used to heal wounds, but this property has not been investigated to prevent the occurrence of pressure ulcers. So the research team decided to evaluate this feature as well.

Materials and methods

This clinical trial study was performed on 102 patients admitted to the intensive care unit located at Besat Hospital in 2020. Samples were assigned to three groups control, placebo, and intervention using permutation blocks. Before the intervention, the questionnaire of demographic and clinical variables, level of consciousness, Braden scale, and short nutritional status questionnaire was completed by the main researcher. In the intervention group, in addition to routine care, 2 cc of fish oil was gently rubbed into the sacrum once a day for 5 days. The same intervention was repeated in the placebo group, with the difference that soybean oil was used instead of fish oil, and the control group received only the usual care. The daily evaluation of pressure ulcers by one of the ICU nurses lasted up to 6 days.

Results

The results showed that there was a significant difference in the incidence of pressure ulcers in the three groups (P = 0.043). The risk of pressure ulcers in the control group was 11.9 and 2.7 times higher than the fish oil group and placebo group (P = 0.023) & (P = 0.132).

Conclusion

The use of topical fish oil can be effective in preventing pressure ulcers.

Is caring for pressure ulcers in the intensive care unit in Spain still a challenge? A qualitative study on nurses' perceptions

BACKGROUND

The incidence of pressure ulcers is an indicator of quality in intensive care units. Due to their frequency and severity, they are identified as a problem of great importance, where the well-being of patients and relatives is compromised, also generating a high healthcare cost. Nurses are primarily responsible for the care of pressure ulcers, however, the existing literature exposes a clear lack of knowledge regarding its prevention and treatment.

OBJECTIVES

To explore the attitudes, knowledge and perceived barriers by intensive care nurses regarding pressure ulcers treatment and prevention in a critical care setting.

DESIGN

A descriptive qualitative study has been carried out through semi-structured interviews with 22 intensive care nurses from two tertiary university hospitals in Spain. The consolidated criteria for reporting qualitative research (COREQ) guidelines were used to reinforce the methodological approach of the study.

FINDINGS

From the collected data, 4 main themes emerged: "lack of specific knowledge about pressure ulcers in intensive care", "continuity of care: the main problem to solve", "teamwork and pressure ulcers: gasping for improvement" and "Skin care as another vital sign".

CONCLUSION

Most intensive care nurses consider that they do not have sufficient knowledge regarding pressure ulcers. The nurses' attitudes are positive, however, an ineffective transmission of information and registration regarding ulcers is perceived. Regarding the treatment of pressure ulcers, the lack of continuity of care and updated knowledge/training have been the main barriers. In terms of prevention, the most mentioned barriers have been the clinical condition of the patient and the lack of personnel, despite the level of knowledge.

Hospital-acquired Pressure Ulcers in Trauma Patients: A Retrospective Study of 410 Patients at a Referral Trauma Center in the North of Iran

Background:

Pressure ulcers (PUs) are among the most common chronic ulcers and complications of hospitalization.

Objective:

The present study aims to evaluate the prevalence of hospital-acquired PUs and their grades in trauma patients, comparing demographic characteristics, clinical features, and outcomes among patients without and with PUs referred to a trauma center in the North of Iran.

Methods:

In a retrospective study, 410 patients with trauma referred to a trauma center in the North of Iran were enrolled. Data were collected using a simple random sampling from March 2019 to September 2019.

Results:

The prevalence of PU in patients with trauma was 27.6%. Grade III (35.5%) and grade I (3.5%) wounds had the highest and lowest frequency of PU, respectively (P<0.001). The mean age of patients with PU was higher than patients without PU (61.73 vs. 47.71 years, P<0.001). The mean hemoglobin level of patients with PU was lower than patients without PU (9.93 vs. 12.25, P<0.001). PUs were more common in smokers compared to non-smokers (P<0.001), with a history of PU (P<0.001), a history of diabetes mellitus (P<0.001), and a history of hypertension (P<0.001). The mean length of stay in the hospital for patients with PU was higher than for patients without PU (13.02 vs. 5.54 days, P<0.001). 74.3% of people with PUs were completely immobile (P<0.001), and 60% of them had mild brain damage (GCS of 13 to 15). Also, the number of people with severe and moderate brain injury among PUs patients was 15% and 24.7%, respectively (P<0.001). Mobility, brain damage, Hemoglobin rate and smoking status were risk factors for pressure ulcers.

Conclusion:

Therefore, it is recommended that health managers and policymakers develop care and treatment plans by considering these risk factors.

Use of propolis for skin wound healing: systematic review and meta-analysis

Propolis is a natural resin that is produced by bees. It has anti-inflammatory and antibiotic properties, promotes reepithelization, and stimulates skin regeneration. Propolis has great potential for the development of new therapeutic approaches to treat skin ulcers. The present study performed a systematic review and meta-analysis of published studies of the use of propolis for the regeneration of cutaneous wounds and its efficacy as a therapeutic agent. Data were collected from articles in the PubMed, SCOPUS, and Web of Science databases that were published since 1900 by searching the terms "propolis" AND "wound healing." This search yielded 633 articles, of which 43 were included in this systematic review and meta-analysis. The results showed that interest in the therapeutic efficacy of propolis has increased over the years. The studies reported that the propolis was effective for the treatment of skin ulcers by promoting a higher percentage of healing than classically employed interventions. The mode of propolis application has also evolved. An increasing number of studies combined it with other substances and materials to achieve additive or synergistic effects on the skin regeneration process. Propolis appears to be an effective therapeutic alternative for the treatment of skin ulcers.

Deep sedation predicts pressure injury in patients admitted to intensive care units

BACKGROUND

Patients in intensive care units (ICU) are frequently prescribed sedatives, which might increase the risk for pressure injury (PI). Although the association between sedation and incidence of PI has been noted, the adequate sedation level to prevent the incidence of PI in patients admitted to ICU is still unclear.

AIM

This study aimed to investigate the association between fluctuating sedation levels and the incidence of PI in patients admitted to ICU.

STUDY DESIGN

We retrospectively reviewed the medical records of 104 patients admitted to ICU. Data regarding the length of ICU stay (LOS) and comorbid infection were abstracted from medical records. The Richmond Agitation-Sedation Scale (RASS) was scored twice per day, and the standardized RASS (S-RASS, summation of RASS values divided by the number of samples) was used to evaluate changes in sedation levels.

RESULTS

Among the 104 included patients, 65 patients (62.5%) were male (median age: 68.0 years), and 13 patients (12.5%) had PI during ICU admission. S-RASS scores were lower in patients with PI than in those without PI (P = .0001) even after adjustment for confounders (OR [95%CI]: 0.14 [0.03-0.58], P = .006). The LOS and infections were higher in patients with PI than in those without PI (P < .0001 and P = .005, respectively). The cut-off value of S-RASS for PI incidence was -3.2 (sensitivity: 88%; specificity: 85%), and a significant predictor of PI incidence (HR [95%CI]: 20.07 [2.53-159.11], P = .005).

CONCLUSIONS

Deeper sedation levels based on S-RASS scores, which account for the effects of fluctuating sedation levels, were a strong, highly accurate predictor of PI incidence in patients admitted to ICU.

RELEVANCE TO CLINICAL PRACTICE

Assessing fluctuations in the level of sedation using the S-RASS might help to identify sedative-induced PI in patients admitted to ICU.

Moving average as a method of assessing risk of pressure injury using the COMHON index (Conscious level, Mobility, Hemodynamic, Oxygenation, Nutrition) for patients in intensive care units

BACKGROUND

Moving average is the continuously updated arithmetic mean of the pressure injury (PI) risk score values measured with the COMHON Index (Conscious level, Mobility, Hemodynamics, Oxygenation, Nutrition).

OBJECTIVE

The objective of this study was to validate the moving average as a method to measure the level of risk of PI.

METHOD

This is a cohort study of adult patients admitted for a duration of more than 24 h in an intensive care unit (ICU) of a tertiary-level university hospital, between June 1, 2018, and December 31, 2019. The risk of PI was obtained with the COMHON Index, and its 3-day moving average was used to monitor the risk of PI. To assess the predictive ability of the moving average score, a receiver operating characteristic curve analysis was performed, obtaining the area under the curve, and the Youden Index to determine the optimal cut-off point of the PI risk moving average score using the COMHON Index.

RESULTS

A total of 1335 patients (94.6% of admissions) were included, and 82 developed PI (cumulative incidence of 6.1%) in the 18 months of the study. The highest incidence of PI was in the sacrum (49%) followed by the heel (17.6%). The median age was 65 (54-73) years, and the median length of stay was 3.8 (1.9-9) days. The moving average score had an area under the receiver operating characteristic curve of 87% (95% confidence interval: 85%-89%), with a cut-off point of the moving average score ≥11, and the negative predictive value was 99.6%.

CONCLUSIONS

The moving average score combined with a validated scale is a useful method to predict potential PI of patients admitted to the ICU. Its use is suggested for decision-making during the implementation of the care plan related to the prevention of PI in patients admitted to the ICU.

Risk Factors Associated With Pressure Injuries in Surgical Patients: A Retrospective Case-Control Study

PURPOSE

This study aimed to identify predictive risk factors for pressure injury (PI) occurring during surgery.

DESIGN

Retrospective case-control study.

SUBJECTS AND SETTING

Data on records of 6070 patients hospitalized for surgery at Seoul National University Bundang Hospital located in Seoul Korea. Data were collected between May 2013 and December 2014.

METHODS

Anonymized data from patients were accessed via electronic health records, nursing records, direct patient assessment, surgical, clinical laboratory, and anesthesia records, preanesthesia status evaluations, and PI incident reports, and transfusion and extracorporeal circulation reports. Descriptive and logistic regression analyses were conducted.

RESULTS

Three hundred eighty-one of the 6070 patients (6.3%) developed within 24 hours a PI that was associated with surgery. The most common locations for the PIs were the coccyx (15.1%; n = 75) and trunk (chest or abdomen; 15.1%; n = 75). All PIs were classified as stage 1 (66.6%; n = 331) or 2 (33.4%; n = 166). Based on logistic regression results, we found that the risk factors that were independently predictive of surgery-related PIs were patient position during surgery, admission to an intensive care unit after surgery, required blood transfusion during surgery, and duration of surgery.

CONCLUSIONS

This retrospective study identified several risk factors associated with a higher incidence of perioperative PIs in surgical patients. A PI prevention program accounting for these factors could potentially help prevent PIs and their costly complications.

Factors associated with the incidence of pressure wounds in critical patients: a cohort study

OBJECTIVES

to identify the incidence of pressure wound in critical patients and its associated factors.

METHODS

retrospective cohort study, based on the analysis of 369 critical patients' records. Descriptive and inferential statistics were used, as well as logistic regression.

RESULTS

the incidence of pressure wounds was 11.4%. Patients who had been hospitalized for four days or more (OR 2.99; CI95% 1.15-7.78), used nasoenteric tubes (OR: 3.81; CI95%: 1.4010.38), vesical drainage catheters (OR: 4.78; CI95%: 1.31-17.38) and tracheostomy (OR: 3.64; CI95%: 1.48-8.97) had a higher chance of developing pressure wounds. The mean score of the Braden scale among participants who developed (14.2 points) pressure wounds was statistically different (p<0.001) than that of those who did not (12.3 points).

CONCLUSIONS

the incidence of pressure wounds was associated with a higher time in the unit, the use of nasoenteric tubes, vesical drainage catheters, and tracheostomies were associated with a higher time of hospitalization in the unit.

APACHE scoring system and pressure injury risk for intensive care patients: A systematic review and meta-analysis

The present study was designed to determine the association between Acute Physiology and Chronic Health Evaluation (APACHE) scale and elevated pressure injure (PI) risk in intensive care units (ICU) and also evaluate the predictive value of APACHE score in PI patients. Comprehensive strategies were used to search studies from PubMed, Web of Science, and Ovid Embase electronic databases for observational studies that provided data about APACHE scores related to PI in ICU. Eligible studies were selected based on inclusion and exclusion criteria. The pooled SMD with 95% confidence intervals were calculated. A summary ROC curve was plotted to calculate area under curve (AUC) for APACHE-II (15-20). Twenty-one studies involving 11,102 patients who met selection criteria were included. The 11.0% of patients (1229/11102) in ICU developed PIs. Overall, the PI group had a higher score compared with the non-PI group in the APACHE II (22.1 ± 8.0 vs. 14.5 ± 7.4, mean ± SD). The APACHE-III of PI patients was significantly more than that in the non-PI group (79.9 ± 25.6 vs. 59.9 ± 30.4, mean ± SD). The pooled SMD was 0.82 (95% CI: 0.58-1.06, I²  = 91.7%, p-value < 0.001). The subgroup analysis revealed that the risk of PIs did not vary with the type of APACHE score (II, III, IV) and the type of study design (case-control, cross-sectional, cohort, longitudinal study). Proportion of males (I²  = 91.68%, p value = 0.090), publish year (I²  = 91.96%, p value = 0.187) and mean age of patients (I²  = 91.96%, p value = 0.937) were not the sources of heterogeneity. APACHE-II (15-20) achieves the best predictive performance in PI, and the prediction accuracy was balanced with equal sensitivity and specificity (Sen: 0.72, 0.62-0.80; Spec: 1.72, 1.25-2.38). In conclusion, higher APACHE scores are frequently accompanied by a higher incidence of PI among critical-care patients. APACHE-II scores (15-20) satisfactorily predicted PI, and strategies to prevent PI should be aggressively implemented.

Pressure injury prevention practices of intensive care unit nurses in Turkey: A descriptive multiple-methods qualitative study

OBJECTIVE

To examine the thoughts, deliberations and actual practices of intensive care unit (ICU) nurses regarding pressure injury (PI) prevention.

DESIGN

and Methods: This descriptive multi-method qualitative study was conducted using maximum variation sampling. Data were collected through semi-structured non-participating observations and semi-structured face-to-face interviews. The combination of observational and interview data was analysed together with the descriptive content analysis.

FINDINGS

Nine nurses were recruited. The main emerged themes were 'heuristic PI risk assessment', 'PI preventive practices' and 'factors affecting preventive practices.' The nurses performed risk assessment based on patients' activity-mobility level, pressure sources, body mass index, skin condition, nutritional issues, comorbidities, admission diagnosis and age. The PI preventive practices for reducing and relieving mechanical load were repositioning, mobilisation, supporting the body parts, measures for medical devices and applying massage. The practices for improving tissue tolerance were skin cleansing and moisturising, preventing excessive moisture and ensuring food intake. However, these measures did not entirely conform to evidence-based recommendations in actual practice. The nurses attributed the divergences to factors affecting their practice. In this respect, the factors affecting preventive practices were the availability of support materials and skincare products, patient/nurse ratios, the clinical condition of the patient, individual skin characteristics and interdependent nurse roles.

CONCLUSION

ICU nurse practices in PI prevention lack systematic approaches and evidence-based recommendations. These disadvantages emerge as inter- and intra-individual variances in implementing preventive practices in actual practice. Considering these divergences is crucial for the effective management of PI risk.

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

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

Reducing the Incidence and Prevalence of Pressure Injury in Adult ICU Patients with Support Surface Use: A Systematic Review

GENERAL PURPOSE

To provide information on the effectiveness of active and reactive support surfaces in reducing the incidence and prevalence of pressure injuries (PIs) in adult ICU patients.

TARGET AUDIENCE

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

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Distinguish features of active and reactive support surfaces used in the ICU.2. Compare the PI incidence in patients using a variety of support surfaces.3. Synthesize recommendations for the use of support surfaces to reduce the risk of PI in adult ICU patients.

Overall Survival among Patients with Cancer and Pressure Injury and Its Association with Braden Scale Score

Background: The overall survival (OS) of hospitalized cancer patients with pressure injury (PI) has not been studied in a large cohort. Objective: To assess risk factors associated with OS of hospitalized cancer patients with PI. Methods: After IRB approval, charts of 445 hospitalized cancer patients with PI were reviewed. Kaplan-Meier method was used to estimate the OS time and log-rank test was used to assess the association between OS and other variables. Results: Stage 1, 2, 3, 4, deep tissue injury, unstageable, and unknown stage were 79 (17.8%), 91 (20.4%), 24 (5.4%), 3 (0.7%), 144 (32.4%), 36 (8.1%), and 68 (15.3%), respectively. The OS rate is 55.3% at one month. OS is significantly associated with Braden Scale (BS) Score. The OS time is significantly shorter in patients with advanced disease. Conclusion: Cancer patients with PI have limited OS, especially those with ≤14 BS and advanced diseases.

Machine Learning-Based Pressure Ulcer Prediction in Modular Critical Care Data

Increasingly available open medical and health datasets encourage data-driven research with a promise of improving patient care through knowledge discovery and algorithm development. Among efficient approaches to such high-dimensional problems are a number of machine learning methods, which are applied in this paper to pressure ulcer prediction in modular critical care data. An inherent property of many health-related datasets is a high number of irregularly sampled time-variant and scarcely populated features, often exceeding the number of observations. Although machine learning methods are known to work well under such circumstances, many choices regarding model and data processing exist. In particular, this paper address both theoretical and practical aspects related to the application of six classification models to pressure ulcers, while utilizing one of the largest available Medical Information Mart for Intensive Care (MIMIC-IV) databases. Random forest, with an accuracy of 96%, is the best-performing approach among the considered machine learning algorithms.

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

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

Intensive Care Pressure Injuries: A Cohort Study Using the CALCULATE and Braden Scales

OBJECTIVE

Identify both the risk of developing pressure injuries (PIs) by applying the CALCULATE (CriticAL Care pressure ULcer Assessment Tool made Easy) and Braden Scales and the incidence of PIs in adult patients in intensive care.

METHODS

This prospective cohort study was conducted from March 2016 to February 2017 in an adult ICU. The Braden and CALCULATE scales were applied every 48 hours until medical discharge, death, or PI development.

RESULTS

The sample included 100 patients. The investigators obtained 818 evaluations (409 Braden and 409 CALCULATE) with an average of 4.1 observations per patient. According to the CALCULATE scale, 49 participants (49%) were classified as very high risk, compared with 40 participants (40%; P = .204) according to the Braden Scale. Thirty-five patients developed 37 PIs, with a total incidence of 35%. The mean age of patients who developed PIs was 60.3 (SD, 13.7) years, and they averaged 9.2 (SD, 6.8) days of hospitalization, with diagnoses related to cardiorespiratory and neurologic diseases and associated comorbidities of hypertension, diabetes mellitus, and smoking. The most affected site was the sacral region; 64.9% of the injuries were classified as stage 1.

CONCLUSIONS

Patients in intensive care were high risk according to both PI scales, and many developed PIs. It is evident that even when preventive measures are used, they are insufficient without the implementation of preventive protocols.

Fatores associados à incidência de lesão por pressão em pacientes críticos: estudo de coorte

RESUMO Objetivos: identificar a incidência de lesão por pressão em pacientes críticos e os fatores associados à sua ocorrência. Métodos: estudo de coorte retrospectiva, baseando-se na análise dos prontuários de 369 pacientes críticos. Utilizou-se estatística descritiva e inferencial, com regressão logística. Resultados: a incidência de lesão por pressão foi de 11,4%. Pacientes com internação por mais de quatro dias (OR 2,99; IC95% 1,15-7,78), em uso de cateter nasoentérico (OR: 3,81; IC95%: 1,4010,38), cateter vesical de demora (OR: 4,78; IC95%: 1,31-17,38) e traqueostomia (OR: 3,64; IC95%: 1,48-8,97) apresentaram maior chance de desenvolver lesão por pressão. A pontuação média da escala de Braden entre os pacientes que desenvolveram (14,2 pontos) ou não (12,3 pontos) lesão por pressão foi estatisticamente diferente (p<0,001). Conclusões: a incidência de lesão por pressão esteve associada ao maior tempo de permanência na unidade, utilização de cateter nasoentérico, cateter vesical de demora e traqueostomia.

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

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

Effect of interface pressure and skin surface temperature on pressure injury incidence: a turning schedule pilot study

OBJECTIVE

This study aimed to evaluate the interface pressure and skin surface temperature in relation to the incidence of pressure injury (PI) using three different turning schedules.

METHOD

This was a pilot study with a three-armed randomised clinical trial design. Participants at risk of PI and treated in the high dependency care unit in a regional hospital in Makassar, Indonesia participated in this study. Patients were repositioned at three different turning schedules (two-, three- and four-hourly intervals). Interface pressure measurement and skin surface temperature were measured between 14:00 and 18:00 every three days. The incidence of PI was assessed during the two-week observation period.

RESULTS

A total of 44 participants took part in the study. A one-way ANOVA test revealed no difference in interface pressure among the three different turning schedule groups within two weeks of observations: day zero, p=0.56; day four, p=0.95; day seven, p=0.56; day 10, p=0.63; and day 14, p=0.92. Although the average periumbilical temperature and skin surface temperature were not significant (p>0.05), comparison between these observation sites was significant on all observation days (p<0.05). Regarding the incidence of PI, the proportional hazard test for the development of PI in the three groups was considered not different (hazard ratio: 1.46, 95% confidence interval: 0.43-4.87, p=0.54).

CONCLUSION

No difference in interface pressure and incidence of PI on the three turning schedules was observed; however, there was a potential increase in skin surface temperature in comparison with periumbilical temperature for all three turning schedules.

Identification of microRNAs responsive to shear loading in rat skin

Pressure injuries (PIs) are localised skin injuries that result from pressure with or without shear force. Shear force is more destructive than pressure in clinical settings. Therefore, determining the critical external forces is important for selecting the appropriate care to prevent PIs. To quantitatively distinguish pressure and shear loading with high specificity, we focused on microRNAs (miRs). This study aimed to identify the miRs that are distinguishable between pressure with and without shear loading in rat skin. Microarray analysis identified six candidate miRs from the comparisons among the pressure, shear, and unloaded groups. We analysed the expression levels of the candidate miRs in the process of PI development using real‐time reverse transcriptase polymerase chain reaction. In the pressure and shear groups, miR‐92b expressions at 6 hours after loading were 2.3 ± 1.3 and 2.9 ± 1.0, respectively, which were significantly higher than those in the control group (P = .014 and .004, respectively). miR‐877 expression at 6 hours after loading was significantly increased only in the shear group (2.8 ± 0.9) compared with the control group (P = .016). These results indicate that miR‐92b and miR‐877 are promising biomarkers to determine for which external force healthcare professionals should intervene.

Topical Almond Oil for Prevention of Pressure Injuries: A Single-Blinded Comparison Study

PURPOSE

The aim of our study was to determine the effect of topical almond oil for prevention of pressure injuries.

DESIGN

Single-blind randomized clinical trial.

SAMPLE AND SETTING

Patients admitted to an intensive care unit in Besat Hospital, Hamadan, Iran, were invited to participate in the trial. Data were collected over an 8-month period.

METHODS

A convenience sample of 108 patients, using a permuted block randomization method was assigned to 3 equal groups that received the intervention almond oil, placebo (liquid paraffin), or control (standard of care). Data included demographic information, Braden Scale score, and National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel (NPUAP-EPUAP) pressure injury staging system classification score. The intervention and placebo groups received daily application of 6.5 cc of topical almond oil or paraffin to the sacrum, heels, and shoulders for 7 consecutive days. The skin was evaluated for pressure injuries by an expert nurse who was blinded to groups. Chi-square test, analysis of variance, and regression analyses were used to evaluate relationships within and between groups for study variables, incidence of pressure injuries, and duration of time of onset of pressure injuries. P values less than .05 were deemed statistically significant.

RESULTS

The incidence of pressure injury in the almond oil group (n = 2; 5.6%) was lower than that in the placebo (n = 5; 13.9%, P = .189) or control groups (n = 9; 25.1%, P = .024). The incidence of pressure injuries in the control group was 6.8 and 2.12 (P = .227) times higher than that in the almond and placebo groups, respectively. The onset day of a pressure injury occurred 5.4 days after initiation of the protocol in the almond oil group compared to 4.22 days in the control group (P = .023) and 5 days in the placebo group (P = .196).

CONCLUSION

The topical application of almond oil was associated with a lower incidence of pressure injuries and that developed later during the study compared to participants who received paraffin or standard of care only. Further study is recommended to advance this work in populations at risk for pressure injury.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

The Effectiveness of Care Bundles Including the Braden Scale for Preventing Hospital Acquired Pressure Ulcers in Older Adults Hospitalized in ICUs: A Systematic Review

Background:

Despite technological and scientific advances, Hospital Acquired Pressure Ulcers (HAPUs) remain a common, expensive, but preventable adverse event. The global prevalence ranges from 9% to 53% while three million people develop HAPUs in the United States and 60,000 people die from associated complications. HAPU prevalence is reported as high as 42% in ICUs (ICU) costing on average $48,000 to clinically manage.

Objective:

The purpose of this systematic review was to evaluate the effectiveness of multi-component interventions (care bundles), incorporating the Braden scale for assessment, in reducing the prevalence of HAPUs in older adults hospitalized in ICUs.

Methods:

This was a systematic review of the literature using the Cochrane method. A systematic search was performed in six databases (CINAHL, Cochrane Library, Google Scholar, JBI Evidence-Based Practice Database, PubMed, and ProQuest) from January 2012 until December 2018. Bias was assessed with the Critical Appraisal Skills Programme Checklist, and the quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence.

Results:

The search identified 453 studies for evaluation; 9 studies were reviewed. From the analysis, pressure ulcer prevention programs incorporated three strategies: 1) Evidence-based care bundles with risk assessments upon admission to the ICU; 2) Unit-based skincare expertise; and 3) Staff education with auditing feedback. Common clinical management processes included in the care bundles were frequent risk reassessments, daily skin inspections, moisture removal treatments, nutritional and hydration support, offloading pressure techniques, and protective surface protocols. The Braden scale was an effective risk assessment for the ICU. Through early risk identification and preventative strategies, HAPU programs resulted in prevalence reduction, less severe ulcers, and reduced care costs.

Conclusion:

Older adults hospitalized in the ICU are most vulnerable to developing HAPUs. Early and accurate identification of risk factors for pressure is essential for prevention. Care bundles with three to five evidence-based interventions, and risk assessment with the Braden scale, were effective in preventing HAPUs in older adults hospitalized in intensive care settings. Higher quality evidence is essential to better understanding the impact of HAPU prevention programs using care bundles with risk assessments on patient outcomes and financial results.

A 10-Year Prevalence Survey and Clinical Features Analysis of Pressure Injury in a Tertiary Hospital in China, 2009-2018

OBJECTIVE

To describe the 10-year prevalence of pressure injury (PI) in a tertiary hospital in China and determine the clinical characteristics of inpatients with PI.

METHODS

The authors performed a retrospective analysis of PI cases extracted from the electronic health record of a tertiary hospital. The trend of PI prevalence over 10 years was described by estimating the average percent change (EAPC). Comorbidities were described with the Charlson Comorbidity Index (CCI). The clinical characteristics of PI were described using the number of cases and composition ratio.

RESULTS

The overall prevalence of PI was 0.59% (5,838/986,404). From 2009 to 2018, the rate increased from 0.19% to 1.00% (EAPC = 22.46%). When stage I PIs were excluded, the prevalence of PI ranged from 0.15% to 0.79% (EAPC = 21.90%). The prevalence of hospital-acquired PI was 0.13%. Prevalence increased with age (Ptrend < .001) and was significantly higher in men than women (P < .001). Patients with PI were more widely distributed in the ICU (20.58%), vasculocardiology department (11.73%), gastroenterology department (10.18%), and OR (8.29%). Of patients with PI, 71.3% had a CCI score 4 or higher.

CONCLUSIONS

The PI prevalence in the study facility increased rapidly over the study period. Pressure injuries among patients in the gastroenterology department and in the community deserve more attention. The CCI may be a good indicator for PI risk assessment.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Acute Skin Failure in the Critical Care Patient

OBJECTIVE

The purpose of this research was to build on previous work regarding predictive factors of acute skin failure (ASF) in the critically ill population.

METHODS

Researchers conducted a retrospective case-control study with a main and validation analysis. Data were extracted from the New York Statewide Planning and Research Cooperative System. For the main analysis, there were 415 cases with a hospital-acquired pressure injury (HAPI) and 194,872 controls without. Researchers then randomly selected 100 cases with a HAPIs and 300 controls without for the validation analysis. A step-up logistic regression model was used. Researchers generated receiver operating characteristic curves for both the main and validation analyses, assessing the overall utility of the regression model.

RESULTS

Eleven variables were significantly and independently related to ASF: renal failure (odds ratio [OR], 1.4, P = .003), respiratory failure (OR, 2.2; P = < .001), arterial disease (OR, 2.4; P = .001), impaired nutrition (OR, 2.3; P = < .001), sepsis (OR, 2.2; P = < .001), septic shock (OR, 2.3; P = < .001), mechanical ventilation (OR, 2.5; P = < .001), vascular surgery (OR, 2.2; P = .02), orthopedic surgery (OR, 3.4; P = < .001), peripheral necrosis (OR, 2.5; P = .003), and general surgery (OR, 3.8; P = < .001). The areas under the curve for the main and validation analyses were 0.864 and 0.861, respectively.

CONCLUSIONS

The final model supports previous work and is consistent with the current definition of ASF in the setting of critical illness.

The economic impact of pressure ulcers among patients in intensive care units. A systematic review

BACKGROUND

The incidence and prevalence of pressure ulcers in critically ill patients in intensive care units (ICUs) remain high, despite the wealth of knowledge on appropriate prevention strategies currently available.

METHODS

The primary objective of this systematic review was to examine the economic impact of pressure ulcers (PU) among adult intensive care patients. A systematic review was undertaken, and the following databases were searched; Medline, Embase, CINAHL, and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to formulate the review. Quality appraisal was undertaken using the Consensus on Health Economic Criteria (CHEC)-list. Data were extracted using a pre-designed extraction tool, and a narrative analysis was undertaken.

RESULTS

Seven studies met the inclusion criteria. Five reported costs associated with the prevention of pressure ulcers and three explored costs of treatment strategies. Four main PU prevention cost items were identified: support surfaces, dressing materials, staff costs, and costs associated with mobilisation. Seven main PU treatment cost items were reported: dressing materials, support surfaces, drugs, surgery, lab tests, imaging, additional stays and nursing care. The overall validities of the studies varied between 37 and 79%, meaning that there is potential for bias within all the included studies.

CONCLUSION

There was a significant difference in the cost of PU prevention and treatment strategies between studies. This is problematic as it becomes difficult to accurately evaluate costs from the existing literature, thereby inhibiting the usefulness of the data to inform practice. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Heel Pressure Injuries in the Adult Critical Care Population

Patients in critical care units have a multitude of diseases and conditions that contribute to their illness and as such are susceptible to comorbid conditions such as heel pressure injuries. Prevention is a key strategy to avoid heel pressure injury occurrence. Risk factor identification can help a clinician identify those patients at risk for a heel pressure injury requiring timely prevention strategies. The purpose of this article is to raise awareness regarding the critical care patient's vulnerability to heel pressure injuries and strategies that can help avoid their occurrence or expedite their healing if occur.

The Incidence of Pressure Ulcers and its Associations in Different Wards of the Hospital: A Systematic Review and Meta-Analysis

Pressure ulcer is a health problem worldwide that is common among inpatients and elderly people with physical-motor limitations. To deliver nursing care and prevent the development of pressure ulcers, it is essential to identify the factors that affect it. This global systematic review and meta-analysis was conducted with the aim of evaluating the incidence of pressure ulcers in observational studies. In this study, databases including Web of Science, Embase, PubMed, Scopus, and Google Scholar were searched to collect data. Articles published from 1997 to 2017 about the factors influencing the incidence of pressure ulcers were retrieved and their results were analyzed using meta-analysis according to the Random-Effects Model. The heterogeneity of studies was investigated using the I² statistic. Data were analyzed using the R and Stata software (version 14). In this study, 35 studies were included in the final analysis. The results showed that the pooled estimate of the incidence rate of pressure ulcer was 12% (95% CI: 10–14). The incidence rates of the pressure ulcers of the first, second, third, and fourth stages were 45% (95% CI: 34–56), 45% (95% CI: 34–56), 4% (95% CI: 3–5), and 4% (95% CI: 2–6), respectively. The highest incidence of pressure ulcers was observed among inpatients in orthopedic surgery ward (18.5%) (95% CI: 11.5–25). According to the final results, better conditions should be provided to decrease the incidence of pressure ulcers in different wards, especially orthopedics, and in patients with diabetes.

The relationship between obesity and nursing care problems in intensive care patients in Austria

OBJECTIVES

To describe the characteristics and nursing care problems of intensive care patients in Austria stratified by obesity.

BACKGROUND

Obese people in intensive care units (ICUs) present nurses with special challenges. Therefore, nurses need to receive education and training regarding how to treat obese patients to provide them with the best care. Most studies on obesity in ICU patients have not specifically addressed the problems and challenges from the nurses' perspective. This may be because nursing science programmes in Europe rarely introduce the topic of obesity.

DESIGN

This was a secondary data analysis of a longitudinal study.

METHODOLOGY

The "Nursing Quality Measurement 2.0" is the Austrian version of the "International Prevalence Measurement of Care problems". It is an annual cross-sectional study, which has been carried out since 2009. Data from all ICU patients for 2009 to 2018 were extracted and combined into one file (n = 460). The main outcome measures were obesity and various nursing care problems, including care dependency.

RESULTS

Of the ICU patients. 25% were obese. Obese ICU patients suffered significantly more often from diabetes mellitus and endocrine, nutritional, or metabolic diseases than non-obese patients. About 30% of the ICU patients were totally care dependent, and 85.6% of the ICU patients were at risk of developing pressure ulcers, whereas the risk was higher for non-obese than obese patients. ICU patients with a risk of pressure ulcer (measured with the Braden Scale) had a reduced risk of being obese (OR = 0.544).

CONCLUSION

Overall, the prevalence of nursing care problems found in this study was high. No significant differences in the prevalence of nursing care problems between obese and non-obese patients were found. However, because of the increase in the number of obese patients in all nursing settings, a stronger focus on obesity research in the area of nursing science is recommended.

A Comparative Study Between Two Support Surfaces for Pressure Ulcer Prevention and Healing in ICU Patients

Objective The aim of this research was to compare the effectiveness of two mattresses used in intensive care unit (ICU) high-risk patients in terms of pressure ulcers (PUs) prevention and healing. Materials and Methods The studied sample consisted of 70 consecutive patients aged 18 to 65 years hospitalized in two ICUs of a general hospital in Athens, Greece. Virtuoso Mattress System (LINET, Slaný, Czech Republic) was used in 35 patients, and standard memory foam mattress was used in the rest of participants. Patients were firstly assessed on enrollment and then every 72 hours in order to record the appearance or not of PUs, location of PUs, and stage of PUs, with the maximum follow-up not exceeding the 21 days. A number of clinical and biochemical factors, medical treatment, and vital signs were also recorded at each time point. Results Of the 70 patients, 40 (57.1%) were men, and the mean ± standard deviation age of the sample was 46.1 ± 14.5 years. The most common area of PUs was the buttocks (34.3%) followed by the shoulders (22.3%), with no statistically significant difference detected between the two groups. Moreover, the proportion of patients having PUs at stage 2 or higher was 23.8% on the third day after admission and 61.1% on the sixth day, with no difference detected between the two groups. Cox proportional hazard model revealed that the Virtuoso mattress was associated with almost 56% lower risk of developing PUs compared with standard foam mattress (HR [95% CI]: 0.44 [0.20-0.93]). The percentage of patients healed using the Virtuoso mattress was significantly lower compared with the standard foam mattress at all time points, with the results reaching statistical significance only on the 12th day after admission (7.7% vs. 66.7%; p < 0.05). Conclusions The Virtuoso mattress seems to be more effective compared with standard foam mattresses in the prevention of PUs, whereas the standard foam mattresses are more effective in PU healing process.

Incidence of pressure injury and nursing care time in intensive care

Objectives: To correlate the incidence of pressure injury (PI) with the average time of nursing care in an intensive care unit (ICU). Method: Epidemiological, observational, retrospective study, carried out in the ICU of a university hospital. Data were collected by consulting the PI incidence and the average nursing care time from ICU databases between 2010 and 2014. Measures of central tendency and variability, and Pearson’s correlation coefficient were used for data analysis. Results: The average incidence of PI between 2010 and 2014 was 10.83% (SD = 2.87) and the average time spent in nursing care for patients admitted to the ICU was 15 hours (SD = 0.94). There was no statistically significant correlation between the incidence of PI and the nursing care time (r = -0.17; p = 0.199), however, the results suggested an overload on the nursing team. Conclusion: This study confirms the importance of implementing and reassessing the effectiveness of preventive care protocols for PI, in addition to warning about the work overload of nursing in assisting critically ill patients.

Incidência de lesão por pressão e tempo de assistência de enfermagem em terapia intensiva

Objetivos: Correlacionar a incidência de lesão por pressão (LP) com o tempo médio de assistência de enfermagem em unidade de terapia intensiva (UTI). Método: Estudo epidemiológico, observacional, retrospectivo, realizado em uma UTI de um hospital universitário. Os dados foram coletados pela consulta aos bancos de dados de incidência de LP e tempo médio de assistência de enfermagem entre 2010 e 2014. Utilizou-se medidas de tendência central e variabilidade, e coeficiente de correlação de Pearson para análise dos dados. Resultados: A média de incidência de LP entre 2010 e 2014 foi de 10,83% (DP = 2,87) e o tempo médio de assistência de enfermagem despendido aos pacientes internados em UTI foi de 15 horas (DP = 0,94). Não houve correlação estatisticamente significante entre incidência de LP e o tempo de assistência de enfermagem (r = -0,17; p = 0,199), porém os resultados sugeriram sobrecarga da equipe. Conclusão: Este estudo confirma a importância da implementação e reavaliação da eficácia de protocolos de cuidados preventivos para LP, além de alertar sobre a sobrecarga de trabalho de enfermagem na assistência aos pacientes críticos.

OR Time and Sacral Pressure Injuries in Critically Ill Surgical Patients

Critically ill patients are at risk for developing pressure injuries during operative and other invasive procedures. The purpose of this secondary analysis was to explore the relationship of OR time to sacral pressure injuries in critically ill patients using high frequency ultrasound as a method of assessment. The 41 participants examined in this study had both time in the OR and up to eight days of pressure injury data. The multivariable model containing OR bed time, body mass index, and Braden Scale score produced the best prediction of pressure injury (area under the curve = 0.859). A higher body mass index (P = .09), shorter OR bed time (P = .01), and lower Braden Scale score (P = .05) were associated with a greater chance of pressure injury. These results suggest that use of high frequency ultrasound may identify tissue changes before observable skin changes, leading to earlier pressure injury prevention strategies.

Effect of Hydrogel Enriched With Alginate, Fatty Acids, and Vitamins A and E on Pressure Injuries: A Case Series

Pressure injuries are a common kind of skin lesion that may be difficult to treat. The objective of this study was to analyze the effect of hydrogel enriched with alginate, fatty acids, and vitamins A and E in the treatment of pressure injuries. This case series with 12-week follow-up included applying daily dressings with hydrogel, maintaining a photographic record, using planimetry to calculate the lesion area, and classifying the healing process using the Pressure Ulcer Scale for Healing (PUSH). In addition, exudate collection from the ulcers was performed in the beginning and after 12 weeks of treatment to determine the dosage of metalloproteinase 9 (MMP9) and tissue inhibitor of metalloproteinase 1 (TIMP1). Of the 13 patients included in the study, 2 died and 11 were monitored for 12 weeks. Only 1 patient showed full wound healing, but all patients showed a significant 12.19% (p = .023) reduction in the lesion area. The PUSH score was also significantly reduced from 15.9 to 10.54 (p = .0052). Relative to the dosage of metalloproteinase and its inhibitor, there was a reduction in the level of MMP9 and there was no change in the level of TIMP1. This study showed that hydrogel enriched with alginate, fatty acids, and vitamins A and E provided promising results for the treatment of pressure injuries by reducing the lesion area, the general PUSH score, and the amount of MMP9 in the wounds' microenvironment.

Pressure injury risk assessment in intensive care units: Comparison of the reliability and predictive validity of the Braden and Jackson/Cubbin scales

AIMS AND OBJECTIVES

To compare the reliability and predictive validity of the Braden and Jackson/Cubbin PI risk assessment scales in intensive care unit patients.

BACKGROUND

Risk assessment with a standardised tool is the usual intervention for preventing pressure injury. Therefore, tools used to assess pressure injury risk should be valid and reliable for the designated patient population.

DESIGN

A prospective and cross-sectional study adheres to the STARD guideline.

METHODS

This study was conducted between November 2017-April 2018 in the intensive care units of a tertiary level university hospital in Turkey. The study sample consisted of 176 patients admitted to three intensive care units. Risk assessment was performed once daily with the Braden scale, followed immediately with the Jackson/Cubbin scale. Risk assessment was terminated on the day of pressure injury development or upon patient discharge from the intensive care unit. Each patient's final risk assessment was considered in the data analysis.

RESULTS

The Cronbach's alpha coefficient of the Jackson/Cubbin and Braden scales was .78 and .85, respectively. The predictive validity of the Jackson/Cubbin scale was confirmed by a sensitivity of .87, specificity of .84, positive predictive value of .47 and negative predictive value of .97. These values for the Braden scale were .95, .75, .38 and .99, respectively.

CONCLUSION

Both the Jackson/Cubbin and Braden scales are reliable and valid scales for pressure injury risk assessment in intensive care unit patients. However, the predictive ability to determine patients at risk and not at risk for pressure injury was better for the Jackson/Cubbin scale than for the Braden scale.

RELEVANCE TO CLINICAL PRACTICE

Both scales are reliable and valid scales for pressure injury risk assessment. Jackson/Cubbin scale's discriminative ability (between the patients at pressure injury risk and not at pressure injury risk) was better.

Efficacy of pressure ulcer prevention interventions in adult intensive care units: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Pressure ulcers (PUs) are associated with substantial health burden. Patients in intensive care units (ICUs) are at high risk for developing PU. In the absence of large randomised controlled trials (RCTs) that compare commonly known interventions for preventing PU in ICUs, uncertainty remains around the best practice strategy for PU management in adult ICUs. This study, therefore, aims to identify the most effective interventions and combinations of interventions that prevent PU in adult ICU using systematic review and network meta-analysis (NMA).

METHODS AND ANALYSIS

We will search for all published and unpublished RCTs evaluating interventions to prevent PU compared with other PU prevention measures or with usual care in adult ICU. The primary outcomes are the incidence of PUs and PU severity in critically ill patients in ICU. The secondary outcomes include number of PUs per patient and intervention-related harms caused by the prevention intervention or intervention-related harms. All data extraction will be performed by at least two independent reviewers on the basis of a priori developed extraction form. We will evaluate the risk of bias of the included RCTs in accordance with the Cochrane Collaboration's risk of bias tool, and assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation. A standard pairwise meta-analysis and a Bayesian NMA will be conducted to compare the efficacy of different PU prevention interventions. A surface under the cumulative ranking curve will be used to rank the probabilities of each prevention intervention for various outcomes.

ETHICS AND DISSEMINATION

This study will not require the ethics approval as it is a review based on published studies. The findings of this study will be submitted to a peer-reviewed journal for publication. We anticipate that the results of the study will provide the evidence to inform clinicians and guideline developers on determining the best interventions for the prevention of PU in ICU patients.

PROSPERO REGISTRATION NUMBER

CRD42018085562.

Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: A pilot study

This pilot study aimed to evaluate the clinical efficacy and feasibility of a fluidised positioning device to reduce occipital pressure injuries (PIs). A post-test design with a historical control group was used in a 54-bed intensive care unit between September 2017 and August 2018. Patients who were receiving either extracorporeal membrane oxygenation, were mechanically ventilated, or had raised intracranial pressure (≥20) were recruited. The intervention consisted of a fluidised positioning device under the patient's head, and a skin assessment every 8 h. Outcome measures included the occurrence of occipital PIs and registered nurses (RNs)' perspectives of the intervention. Data collected from patients in the intervention group were compared with data obtained from the historical control group between May 2016 and April 2017. Sixty-four patients were recruited in the intervention phase and 63 were in the historical control group. Results showed a statistically significant reduction in occipital PIs by 87.7% (16/63; 25.4% historical control vs 2/64; 3.13% interventional group). Bedside RNs provided positive evaluation of the fluidised positioning device. The findings demonstrate that the fluidised positioning device is a feasible and effective intervention in reducing the risk of occipital PIs in intensive care patients, which merits the continuation of use and further evaluation through a larger-scale study.

Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran

BACKGROUND AND OBJECTIVE

Pressure ulcer (PU) is one of the important and frequent complications of hospitalization, associated with high treatment costs. The present study was conducted to determine the incidence of PU and its direct treatment costs for patients in intensive care unit (ICU) in Iran.

MATERIAL AND METHODS

In this retrospective study, medical records of 643 discharged patients from ICU of two selected hospitals were examined. The demographic and clinical data of all patients and data of resources and services usage for patients with PU were extracted through their records. Data analysis was done using logistic regression tests in SPSS 22 software. The cost of PU treatment was calculated for each grade of ulcer.

RESULTS

The findings showed that 8.9% of patients developed PU during their stay in ICU. Muscular paralysis (OR = 5.1), length of stay in ICU (OR = 4.0), diabetes (OR = 3.5) age (OR = 2.9), smoking (OR = 2.1) and trauma (OR = 1.4) were the most important risk factors of PU. The average cost of PU treatment varied from USD 12 for grade I PU to USD 66 834 for grade IV PUs. The total treatment costs for all studied patients with PU was estimated at USD 519 991.

CONCLUSION

The cost of PU treatment is significant. Since the preventive measures are more cost-effective than therapeutic measures, therefore, effective preventive interventions are recommended.