The relationship between nurses assessment of early pressure ulcer damage and sub epidermal moisture measurement: A prospective explorative study

The correlation between sub-epidermal moisture assessment and other early indicators of pressure ulcer development: A prospective cohort observational study. Part 2. The correlation between sub-epidermal moisture assessment, temperature, epidermal hydration and pain

There is growing interest in the roles of temperature, epidermal hydration (EH) and pain in pressure ulcer (PU) development. Investigating correlations between these measures and sub-epidermal moisture (SEM) will address this knowledge deficit. A prospective observational study enrolled 60 surgical patients from February to November 2021. SEM, temperature, EH and pain were assessed using a SEM scanner, thermography imaging, skin hydration device and numeric pain intensity scale, respectively. Measurements were taken at the sacrum, both heels and a control site, before and after surgery for 3 days. Data were analysed using Pearson or Spearman's correlation. Of the participants, 50% were male with a mean age of 58 years (±13.46). Low positive/negative correlations between SEM and temperature were found at the sacrum. However, after removing outliers, these results were not statistically significant. Other sites and follow-up days showed negligible correlations. No evidence of a correlation, to low correlations between SEM and EH were observed, but unreliable due to little variation in EH at the heels. Pain showed negligible correlations with SEM. This study did not find consistent evidence of a correlation between SEM, temperature, EH and pain, highlighting the unreliability of temperature and EH for early PU detection. Post-operative pain may also confound accurate pain assessments.

Integrating technologies to enhance risk assessment for the early detection and prevention of pressure ulcers

Pressure ulcers (PU) are a globally recognised healthcare concern, with their largely preventable development prompting the implementation of targeted preventive strategies. Risk assessment is the first step to planning individualised preventive measures. However, despite the long use of risk assessment, and the >70 risk assessment tools currently available, PUs remain a significant concern. Various technological advancements, including artificial intelligence, subepidermal moisture measurement, cytokine measurement, thermography and ultrasound are emerging as promising tools for PU detection, and subsequent prevention of more serious PU damage. Given the rise in availability of these technologies, this advances the question of whether our current approaches to PU prevention can be enhanced with the use of technology. This article delves into these technologies, suggesting that they could lead healthcare in the right direction, toward optimal assessment and adoption of focused prevention strategies.

Biomarkers of local inflammation at the skin's surface may predict both pressure and diabetic foot ulcers

This commentary considers the similarities which exist between pressure ulcers (PUs) and diabetic foot ulcers (DFUs). It aims to describe what is known to be shared-both in theory and practice-by these wound types. It goes on to detail the literature surrounding the role of inflammation in both wound types. PUs occur following prolonged exposure to pressure or pressure in conjunction with shear, either due to impaired mobility or medical devices. As a result, inflammation occurs, causing cell damage. While DFUs are not associated with immobility, they are associated with altered mobility occurring as a result of complications of diabetes. The incidence and prevalence of both types of lesions are increased in the presence of multimorbidity. The prediction of either type of ulceration is challenging. Current risk assessment practices are reported to be ineffective at predicting when ulceration will occur. While systemic inflammation is easily measured, the presence of local or subclinical inflammation is harder to discern. In patients at risk of either DFUs or PUs, clinical signs and symptoms of inflammation may be masked, and systemic biomarkers of inflammation may not be elevated sufficiently to predict imminent damage until ulceration appears. The current literature suggests that the use of local biomarkers of inflammation at the skin's surface, namely oedema and temperature, may identify early tissue damage.

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.

Decreasing Intraoperative Skin Damage in Prone-Position Surgeries

OBJECTIVE

To determine if subepidermal moisture (SEM) measures help detect and prevent intraoperative acquired pressure injuries (IAPIs) for prone-position surgery.

METHODS

In this clinical trial of patients (n = 39 preintervention, n = 48 intervention, 100 historical control) undergoing prone-position surgery, researchers examined the use of multidimensionally flexible silicone foam (MFSF) dressings applied preoperatively to patients' face, chest, and iliac crests. Visual skin assessments and SEM measures were obtained preoperatively, postoperatively, and daily for up to 5 days or until discharge. Electronic health record review included demographic, medical, and surgery data.

RESULTS

Of the 187 total participants, 76 (41%) were women. Participants' mean age was 61.0 ± 15.0 years, and 9.6% were Hispanic (n = 18), 9.6% were Asian (n = 18), 6.9% were Black or African American (n = 13), and 73.8% were White (n = 138). Participants had a mean Scott-Triggers IAPI risk score of 1.5 ± 1.1. Among those with no erythema preoperatively, fewer intervention participants exhibited postoperative erythema on their face and chest than did preintervention participants. Further, fewer intervention participants had SEM-defined IAPIs at all locations in comparison with preintervention participants. The MFSF dressings overcame IAPI risk factors of surgery length, skin tone, and body mass index with fewer IAPIs in intervention participants.

CONCLUSIONS

Patients undergoing prone-position surgeries developed fewer IAPIs, and SEM measures indicated no damage when MFSF dressings were applied to sites preoperatively. The SEM measures detected more damage than visual assessment.

A systematic review on the impact of sub-epidermal moisture assessments on pressure ulcer/injury care delivery pathways

To assess all published studies which describe what happens to the delivery of pressure ulcer/injury (PI/PU) care pathways as a result of detecting raised sub-epidermal moisture (SEM) delta (∆ ≥ 0.6). We undertook a systematic review of the literature, and included original research studies using either a prospective or retrospective study design that report the impact that assessment using SEM assessments have on healthcare practitioners' delivery of PI/PU care pathways in adults at risk of developing PI/PUs. The review protocol was registered on PROSPERO (CRD42023416975). A literature search was conducted in May 2023, using PubMed, CINAHL, Scopus, Cochrane, EMBASE, Web of Science and Science Direct databases. Data were extracted using a data extraction tool including elements such as country, setting, sample size, intervention, control and quality appraisal was undertaken using the Evidence-based Librarianship. We identified nine papers published between 2017 and 2022. The majority of these studies were conducted in England (n = 6; 67%). The systematic review included studies conducted across multiple care settings including acute care, medical-surgical units, and palliative care, highlighting the importance of PI/PU prevention and management across diverse patient populations. The PI/PU care pathways implemented in the studies varied, but commonly included elements such as the application or increased use of pressure-redistributing mattresses/cushions, implementation of repositioning plans, management of incontinence and moisture, regular skin inspection, and assessment of patient mobility. Out of the nine studies identified, seven reported PI/PU incidence. A meta-analysis of seven studies (N = 18 451) demonstrated a statistically significant reduction in visual PI/PU development in favour of SEM-guided care pathways compared to usual care (the odds ratio = 0.36 [95% confidence interval: 0.24-0.53, p < 0.00001]). This systematic review provides evidence that implementing SEM assessments in patients at risk of developing PI/PUs prompts anatomy-specific clinical actions. The subsequent implementation of enhanced and targeted skin care interventions leads to consistent and sustained reductions in hospital-acquired PU incidence. The findings emphasise the importance of incorporating SEM assessments as part of comprehensive PI/PU prevention strategies in all care settings and patient populations. This systematic review is limited by the predominance of observational studies and variable study quality. Future research should focus on randomised trials in different care settings that monitor the efficacy of preventive interventions and their impact in reducing PI/PU incidence when implemented based on SEM assessments.

Enhanced Skin Assessment Methodology to Detect Early Tissue Damage and Prevent Pressure Injuries

PURPOSE

The purpose of this study was to evaluate a skin assessment technique, subepidermal moisture (SEM) assessment, to assess, identify, and prevent pressure injuries (PIs) in critically ill adults.

DESIGN

This was a retrospective, descriptive, comparative research study.

SUBJECTS AND SETTING

The sample comprised 69 critically ill adults; their mean age was 58.8 years (SD 18.1 years). The majority were male (n = 40, 58%), 29 (42%) were African American (AA), and 36 (52%) were White. The study setting was a surgical trauma intensive care unit (STICU) in a southern US Gulf Coast academic level I trauma hospital. Data were collected from September to November 2021.

METHODS

We conducted a retrospective medical record review of subjects who had undergone SEM assessment. We also collected demographic and pertinent clinical information, including Braden Scale cumulative scores and subscale scores, documented PI prevention interventions, and PI occurrence and characteristics if developed within 7 days of SEM measurement. We also evaluated whether PI prevention interventions were appropriate. To examine nurse perception of the SEM device, we conducted a web-based survey of nurses providing care in our facility's STICU. Comparison of responses was done using Fisher's test or Chi-square test, and the mean responses from groups were compared using t test.

RESULTS

Thirty-five (57%) subjects had a sacral SEM delta ≥0.6; 14 (40%) were AA; 20 (57%) were White; and 11 (31%) had a hospital-acquired PI (HAPI) or present-on-admission (POA) PI. Among the 14 HAPI and POA PI subjects with sacral SEM delta, 11 (79%) had sacral SEM delta ≥0.6. Among 26 AA subjects with sacral SEM delta, 5 had a HAPI or POA PI, and of those, 4 (80%) had sacral SEM delta ≥0.6. A significant and negative correlation was observed between cumulative Braden Scale scores on day 2 and sacral SEM delta (r = -0.28, P = .03) and R heel delta (r = -0.29, P = .03) scores, indicating higher PI risk. Of the 35 patients with a sacral SEM delta ≥0.6, 24 (69%) subjects did not have appropriate PI prevention interventions. Nurses (n = 13) indicated that the SEM device was easy to use and helped them perform an accurate skin assessment on patients with darker skin tones.

CONCLUSIONS

This study demonstrates that SEM technology is beneficial to address racial disparities in skin assessment, enhance skin assessment accuracy beyond existing PI care, improve the accuracy of risk assessment, and promote appropriate location-specific PI prevention interventions.

The correlation between sub-epidermal moisture measurement and other early indicators of pressure ulcer development-A prospective cohort observational study. Part 1. The correlation between sub-epidermal moisture measurement and ultrasound

The correlation between sub-epidermal moisture (SEM) and other early indicators of pressure ulcer (PU) development is yet to be determined. This three-part series aims to bridge this knowledge gap, through investigating SEM and its correlation with evidence-based technologies and assessments. This article focuses on the correlation between SEM and ultrasound. A prospective cohort observational study was undertaken between February and November 2021. Patients undergoing three surgery types were consecutively enrolled to the study following informed consent. Assessments were performed prior to and following surgery for 3 days at the sacrum, both heels and a control site, using a SEM scanner and high-frequency ultrasound scanner (5-15 MHz). Spearman's rank (rs ) explored the correlation between SEM and ultrasound. A total of 60 participants were included; 50% were male with a mean age of 58 years (±13.46). A statistically significant low to moderately positive correlation was observed between SEM and ultrasound across all anatomical sites (rs range = 0.39-0.54, p < 0.05). The only exception was a correlation between SEM and ultrasound on day 0 at the right heel (rs  = 0.23, p = 0.09). These results indicate that SEM and ultrasound agreed in the presence of injury; however, SEM was able to identify abnormalities before ultrasound.

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.

Validation of a sub-epidermal moisture scanner for early detection of pressure ulcers in an ex vivo porcine model of localized oedema

Pressure ulcers (PUs) remain a chronic health problem with severe impacts on healthcare systems. Early detection is crucial to providing effective interventions. However, detecting PUs currently relies on subjective tissue evaluations, such as visual skin assessment, precluding interventions prior to the development of visible tissue damage. There is an unmet need for solutions that can detect early tissue damage before visual and tactile signs occur. Assessments based on sub-epidermal moisture (SEM) measurements represent an opportunity for robust and objective early detection of PUs, preventing broken skin PUs in more high-risk patients at high-risk anatomical locations. While SEM assessment technology has been validated in computational, bench and tissue phantom models, validation in soft tissue was absent. In this study, we successfully validated the ability of a commercially available SEM assessment device to measure and detect sub-epidermal moisture changes in a novel ex vivo porcine soft tissue model of localised oedema. When controlled and incremental fluid volumes (Phosphate Buffer Solution) were injected into porcine soft tissues, statistically significant differences were found in SEM values between fluid-injected sites, representing an inflammatory oedematous condition, and healthy tissue control sites, as measured by the SEM device. The device provided reproducible readings by detecting localised oedema changes in soft tissues, reflecting the build-up of fluid as small as 1 ml into the underlying tissue. Spatial characterization experiments described the ability of the device technology to differentiate between healthy and oedematous tissue. Our findings validate the use of SEM assessment technology to measure and quantify localized oedema.

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.

Variations in sacral sub-epidermal moisture measurements in hospitalized medical and surgical patients: A longitudinal observational sub-study

BACKGROUND

Pressure injury risk assessment tools have several well-known limitations. As a result, new methods of assessing risk are emerging, including the use of sub-epidermal moisture measurement to detect localized edema.

AIMS

To assess the daily variation in sacral sub-epidermal moisture measurement over five days and establish if age and prophylactic sacral dressing use influenced these measurements.

METHODS

As part of a larger randomized controlled trial of the use of prophylactic sacral dressings, a longitudinal observational substudy was undertaken in hospitalized medical and surgical adult patients at risk of pressure injury. The substudy was conducted in consecutively recruited patients from 20 May 2021 to 9 November 2022. Using the SEM 200 (Bruin Biometrics LLC), daily sacral sub-epidermal measurements for up to five days were completed. Two measurements were generated, the most recent sub-epidermal moisture measurement and, after at least three measurements, a delta value, the difference between the highest and lowest values. The delta measurement was the outcome, with a delta of ≥0.60 considered abnormal, increasing the risk of pressure injury development. A mixed analysis of covariance was undertaken to determine if there was any change in delta measurements over the five days and to determine if age and sacral prophylactic dressing use influenced sub-epidermal moisture delta measurement.

RESULTS

A total of 392 participants were included in this study; 160 (40.8%) patients had completed five consecutive days of sacral sub-epidermal moisture delta measurements. In total, 1324 delta measurements were undertaken across the five study days. In total, 325 of 392 patients (82.9%) had experienced one or more abnormal delta. Furthermore, 191 (48.7%) and 96 (24.5%) of patients experienced abnormal deltas for two or more and three or more consecutive days. There was no statistically significant variation in sacral sub-epidermal moisture delta measurements over time; increasing age and prophylactic dressing use did not influence sub-epidermal moisture deltas over the five days.

CONCLUSION

If only one abnormal delta was used as a trigger, about 83% of patients would have received additional pressure injury prevention strategies. But, if a more nuanced approach to responding to abnormal deltas is taken, between 25 and 50% of patients may receive additional pressure injury prevention, representing a more time and resource efficient approach.

TWEETABLE ABSTRACT

Sub-epidermal moisture delta measurements did not vary over 5 days; increasing age and prophylactic dressing use did not influence these measurements.

Use of point-of-care subepidermal moisture devices to detect localised oedema and evaluate pressure injury risk: A scoping review

AIMS AND OBJECTIVES

To map current literature on bedside clinicians' use of point-of-care subepidermal moisture devices to identify increased pressure injury risk.

BACKGROUND

Pressure injuries are a substantial healthcare burden. Localised oedema occurs before visible or palpable changes, and therefore is a biomarker of increased pressure injury risk. Novel bedside technologies that detect localised oedema may aid early pressure injury preventative practices.

DESIGN

A scoping review.

METHODS

Arksey and O'Malley's six-step framework and the PRISMA-ScR guidelines guided this scoping review. CINAHL Complete, Embase, SCOPUS, Cochrane (wounds) and PubMed databases were searched for primary research and quality improvement projects published in English between 2008-2022. Included studies focused on clinicians' bedside use of subepidermal moisture devices to quantify localised oedema and pressure injury risk. The PAGER framework supported narrative synthesis of the extracted data.

RESULTS

Nine studies were selected from 1676 sources. Two point-of-care subepidermal moisture devices were identified in clinical use, largely by nurses. Inconsistent use and interpretations revealed significant knowledge gaps in clinical practice. Additionally, no included studies engaged patients or the public in their design.

CONCLUSIONS

Nurses recognise the value of objective measures in determining the risk of pressure injury and are the primary end-users of point-of-care subepidermal moisture devices. However, standardising procedural instructions and interpretive criteria to guide preventative measures requires further research.

RELEVANCE TO CLINICAL PRACTICE

International pressure injury clinical practice guidelines advocate for subepidermal moisture devices as an adjunct to routine clinical skin assessment, although little is known about bedside use. This scoping review reveals low adoption of such devices and the need to develop standardised procedures in their use and interpretation.

REGISTRATION

Open Science DOI https://doi.org/10.17605/OSF.IO/AB6Y5-7th of March 2022.

Sub epidermal moisture measurement and targeted SSKIN bundle interventions, a winning combination for the treatment of early pressure ulcer development

This study aimed to investigate the impact of sub epidermal moisture (SEM) measurement and targeted pressure ulcer (PU) prevention, versus visual skin assessment and usual care, on mean SEM delta scores and early pressure ulcer development in acute hospital patients. A quantitative quasi-experimental observational approach was used. A total of 149 at risk acute hospital patients took part, 78 treatment, and 71 control. SEM deltas were recorded daily for a maximum of 5 days using the SEM Scanner (Bruin Biometrics LLC, Los Angeles, California), on three sites: the sacrum, the right heel, and the left heel, with enhanced and targeted PU prevention interventions occurring in those with an elevated SEM delta scores in the treatment group. Intention to treat analysis was used to guide the final composition of results. SEM PU represents PU development as identified by 2 days of sustained abnormal SEM delta scores, ≥0.5, after day one. The mean number of days completed by participants was just under 4 days, participants had many different comorbidities, with the most common being: hypertension, cancer, and chronic obstructive pulmonary disease. Results showed that following the introduction of SEM guided targeted treatments, participants in the treatment group yielded a statistically significant reduction in mean SEM delta scores (MD: 0.49; 95% CI: 0.59, 0.39; P < .0001), and in the odds of developing a SEM PU (OR: 0.59, 95% CI: 0.24 to 1.00; P = .05). In the treatment group, none of the participants developed a visual PU, whereas, in the control group, 1.41% (n = 1/71) developed a visual PU. Based on all the results, the following is concluded, (1). There was a greater reduction in mean SEM delta scores among those cared for using SEM measurement and targeted PU prevention, versus those cared for using visual skin assessment and usual care, and (2). the mean SEM delta scores was statistically significantly lower at the study end for those who received targeted treatments based on abnormal SEM scores. More research is now needed in other and larger at-risk groups to further validate what was found in this study.

The effect of head of bed elevation on sacral and heel subepidermal moisture in healthy adults: A randomised crossover study

BACKGROUND

Subepidermal moisture (SEM) changes may detect early tissue injury and enhance pressure injury risk assessments. However, little is known how modifiable factors, like head of bed elevation (HOBE), affect SEM.

AIM

This study investigated the influence of HOBE on sacral and heel SEM, using the Provizio ® SEM Scanner.

METHOD

A 2 × 2 randomised crossover study compared the effects of 30-min of 30⁰ versus 60⁰ HOBE on sacral and heel SEM in healthy adults.

RESULTS

48 participants were randomly allocated to 30⁰ or 60⁰ HOBE and crossed over after a 60-min washout period. The mean age was 40.6 years (SD = 18.3). The study found the sacral and heel SEM values were not statistically different at 30⁰ versus 60⁰ HOBE. No clinically relevant association between SEM and characteristics of age, sex, body mass index and skin type were found. Baseline sacral and heel SEM values recovered after a 60-min washout period. Notably, half of the initial baseline measures suggested pressure injury risk.

CONCLUSION

The HOBE may not influence SEM at the sacrum and heels, in healthy adults after 30 min of loading. Standard operating procedures for measuring SEM for pressure injury risk assessment require a stronger body of evidence in varied populations and timeframes before this technology is widely adopted.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12622001456741.

Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BACKGROUND

Subepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.

AIM

The primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.

METHODS

Healthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.

RESULTS

A total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.

CONCLUSION

In a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial

AIM

Sub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS.

MATERIALS AND METHODS

This pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes.

RESULTS

Of 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing.

CONCLUSIONS

Most feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.

Biomarkers for the early detection of pressure ulcers in the intensive care setting: A comparison between sub-epidermal moisture measurements and interleukin-1α

Pressure ulcer (PU) prevention in the intensive care unit (ICU) is an important clinical issue as critically unwell patients are at high risk of developing PUs. However, current methods of PU detection are limited, especially for early detection. This study aimed to establish the correlation between Interleukin-1α (IL-1α)/total protein (TP) and sub-epidermal moisture (SEM) measurements in the early identification of PUs in ICU patients. This study employed an observational research design using the STROBE guidelines. Following ethical approval, 53 participants were recruited and sebum was obtained using Sebutape from weight-bearing areas (sacrum, heels and a control site). SEM measurements were taken from the same anatomical sites. Both measures were taken at the same time and participants were followed up for 5 days, or until discharge or death. Correlations between SEM delta measurements, IL-1α, TP and PU incidence and other demographic information were explored using Spearman's correlation for data not normally distributed, and Pearson's R correlation coefficient for normally distributed data. Mean baseline SEM delta measurements indicate abnormal readings for all anatomical sites except the control site, consistent with previous studies. Mean baseline IL-1α/TP readings were higher for the sacrum versus both heels and, on average, readings were higher for the control site versus all other anatomical locations. This is conflicting, given that the control site was non-weight bearing. There were very weak or weak correlations between SEM delta measurements and IL-1α/TP readings. SEM measurements are quick and easy to obtain and results are instant, however Sebutape sampling takes significantly longer and is challenging to conduct among haemodynamically unstable patients. Obtaining SEM measurements is more practical and feasible than Sebutape sampling to assess for the presence of inflammation.

Measuring subepidermal moisture to detect early pressure ulcer development: a systematic review

OBJECTIVE

The aim was to assess evidence related to the measuring of subepidermal moisture (SEM) to detect early, nonvisible development of pressure ulcers (PUs).

METHOD

Using systematic review methodology, all quantitative animal and human research studies written in English were considered. In January 2021, PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases were searched. The primary outcome of interest was the validity of SEM measurement to detect early PU development. The secondary outcome was time to PU detection, sensitivity and specificity of SEM measurement, and the impact of SEM measurements on PU prevention. Data analysis was undertaken using RevMan and narrative synthesis.

RESULTS

A total of 17 articles met the inclusion criteria. In all studies, a consistent abnormal deviation in SEM measurements corresponded with evidence of visual PU development. Time to PU development, explored in four studies, showed earlier detection of PU development using SEM measurement. RevMan analysis identified the mean difference in time to PU development (SEM measurement versus visual skin assessment, VSA) was 4.61 days (95% confidence interval: 3.94-5.28; p=0.0001) in favour of SEM measurements. The sensitivity of SEM measurements was reported in four studies, and scores varied from 48.3% to 100.0%. Specificity was also reported in four studies and scores ranged from 24.4% to 83.0%. The impact of the detection of abnormal SEM measurements on PU prevention was explored by one study. Results showed a 93% decrease in PU rates when staff acted on the results of the SEM readings.

CONCLUSION

The findings of this review identified that SEM measurement detects PU development earlier than VSA. Furthermore, when staff responded to abnormal SEM measurements, prevention strategies were enhanced, with a subsequent reduction in visible PU development. SEM measurement may therefore be a useful addition to PU prevention strategies.

DECLARATION OF INTEREST

The School of Nursing & Midwifery, RCSI has a research agreement with Bruin Biometrics. Funding for the study was through an Irish Research Council PhD Enterprise Partnership Scheme with Bruin Biometrics. The authors have no other conflicts of interest.

Oedema as a predictor of the incidence of new pressure injuries in adults in any care setting: A systematic review and meta-analysis

BACKGROUND

Oedema measurement, also termed sub-epidermal moisture measurement is recommended as an adjunct pressure injury prevention intervention in international guidelines because it indicates early tissue damage.

OBJECTIVE

To determine the prognostic value of oedema measurement in predicting future pressure injury in adults in any care setting.

DESIGN

Systematic review and meta-analysis.

SETTING

Participants were recruited from nursing homes or aged care facilities, hospitals, or post-acute facilities.

PARTICIPANTS

Adults.

METHODS

A modified 2-week systematic review was undertaken. Study designs included cohort (prospective and retrospective), case-control, case series if relevant comparisons were reported, randomised controlled trials if the association between oedema measurement and pressure injury was reported, and registry data. Databases searched included: Medical Literature Analysis and Retrieval System Online, The Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica and the Cochrane Library from inception to 13 July 2021 with no language restrictions. Screening, data extraction using Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies - Prognostic Factors (CHARMS-PF) and quality assessment using Quality in Prognostic Factor Studies (QUIPS) were undertaken independently by ≥2 authors and adjudicated by another if required. Meta-analyses and meta-regression were undertaken. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Six studies (n = 483 total) were included. Two studies were set in nursing homes and four in either hospitals or post-acute facilities. Fives studies were prospective cohorts, and one was a randomised control trial. Two studies were assessed as low risk and four studies as moderate risk of bias. The pooled risk ratio in four studies (n = 388) for the relationship between oedema and pressure injury cumulative incidence was 18.87 (95% CI 2.13-38.29) and for time to pressure injury was 4.08 days (95% CI 1.64-6.52). Using GRADE, the certainty of the body of evidence was low for all outcomes. Meta-regression indicated that age, gender, and sample size were poor predictors for the association between oedema and pressure injury.

CONCLUSIONS

Measuring oedema as a predictor for pressure injury development is showing promise but a stronger body of evidence that takes into consideration other prognostic factors is needed to better understand its benefit.

REGISTRATION

PROSPERO CRD42021267834.

TWEETABLE ABSTRACT

Measuring oedema is a promising strategy to prevent pressure injuries but the certainty of evidence for this claim is low.

Sub-epidermal moisture versus traditional and visual skin assessments to assess pressure ulcer risk in surgery patients

OBJECTIVE

To compare the predictive ability of subepidermal moisture (SEM) measurement versus traditional risk assessment and visual skin assessment (VSA) as means of detecting early pressure ulcer (PU) damage development among adults undergoing surgery.

METHOD

A non-experimental, comparative, descriptive cohort study design was used. Following ethical approval, participants who had given their informed written consent had their skin assessed over the areas that were weight-bearing during surgery, using VSA and the SEM measurement. Visual PUs were graded according to the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel ulcer grading system. Assessments took place preoperatively, then daily on the ward, beginning on day one postoperatively and continuing for three days or until discharge.

RESULTS

Of the 231 participants, who had a mean age of 57.50 years, 55.8% (n=129) were male. The most common comorbidity was cardiology/vascular (n=42; 18.2%). Just over half (52.4%; n=121) underwent orthopaedic surgery and 47.6% (n=110) underwent non-orthopaedic surgery; 70% (n=163) received a general anaesthetic and 43% (n=100) were in the supine decubitus position during surgery. PU incidence was 51% (n=116), according to SEM measurement, and 3% (n=7) according to VSA. Among the seven participants who developed a visual PU, 10 PUs at stage 1 developed (31%); some patients developed more than one PU. Of the participants who had assessments for three days postoperatively, 94% (n=61) had a persistently high SEM delta on day three. The variables that emerged as statistically significantly related to abnormal SEM measurement deltas among these participants were: surgery duration (p=0.038); having orthopaedic surgery (p=0.020); supine surgical position (p=0.003); spinal anaesthetic type (p=0.0001); and Waterlow and Braden mobility subscale day one postoperatively (p=0.0001). None of the variables had a statistically significant influence on abnormal VSA.

CONCLUSION

Surgical patients, because of immobility, are vulnerable to the action of compression and shear forces. These forces cause changes at a cellular level that trigger inflammation, which is a precursor to early tissue damage. SEM measurement can detect this tissue damage from the increase in the underlying tissue water content that results from inflammation. From the findings of this study, SEM measurement is very promising in the detection of early tissue damage in those at risk of PU development among the surgical population.

A Study on Pressure Ulcer: Influencing Factors and Diagnostic Techniques

Pressure ulcer (PU) is one of the most common occurrences in bedridden subjects. Despite the standard of care, there is a huge challenge in monitoring immobile subjects in all the bodily pressure points. This increases the chance of onset of PU which in turn increases the expenditure for treating and managing the PU. Hence, we made a study on the biological and physiological factors that are responsible for the formation of PU and also on various techniques used for diagnosis. Thus, we have summarised the efficacy of various advanced diagnostic procedures with their limitations. Though there are advanced imaging techniques, risk assessment tools based on the visual inspection are widely followed in hospitals. Based on our observation, we here have identified three major areas; one being the development of mathematical modeling, the second is towards the development of non-invasive devices and finally to automate cot facility. We have also provided possible suggestions as to solutions that could be useful to researchers and for society. Thus, this review covers the present difficulty faced by bedridden subjects and respective care-takers along with the knowledge gap and a few suggestions as to future scope.

A machine learning algorithm for early detection of heel deep tissue injuries based on a daily history of sub-epidermal moisture measurements

Sub‐epidermal moisture is an established biophysical marker of pressure ulcer formation based on biocapacitance changes in affected soft tissues, which has been shown to facilitate early detection of these injuries. Artificial intelligence shows great promise in wound prevention and care, including in automated analyses of quantitative measures of tissue health such as sub‐epidermal moisture readings acquired over time for effective, patient‐specific, and anatomical‐site‐specific pressure ulcer prophylaxis. Here, we developed a novel machine learning algorithm for early detection of heel deep tissue injuries, which was trained using a database comprising six consecutive daily sub‐epidermal moisture measurements recorded from 173 patients in acute and post‐acute care settings. This algorithm was able to achieve strong predictive power in forecasting heel deep tissue injury events the next day, with sensitivity and specificity of 77% and 80%, respectively, revealing the clinical potential of artificial intelligence‐powered technology for hospital‐acquired pressure ulcer prevention. The current work forms the scientific basis for clinical implementation of machine learning algorithms that provide effective, early, and anatomy‐specific preventive interventions to minimise the occurrence of hospital‐acquired pressure ulcers based on routine tissue health status measurements.

Developing Algorithm Based on Activity and Mobility for Pressure Ulcer Risk Among Older Adult Residents: Implications for Evidence-Based Practice

BACKGROUND

A pressure ulcer (PU) is a localized injury to the skin or underlying tissue usually over a bony prominence. The prevention PU per patient per day is costly; therefore, the detection of a PU at its earliest stage is imperative to afford timely interventions. Currently, there are very few clinically useful tools to assist with early PU detection and prevention.

AIM

There were two primary aims of this study: (1) to investigate the relationship between activity, mobility, and PU development; and (2) to ascertain the next steps for delineating an algorithm based on activity and mobility for detecting PU risk among older adult residents in long-term care.

METHOD

This quantitative, prospective, descriptive, non-experimental study was conducted between July 2019 and March 2020 among 53 older adult residents who were followed for 4 consecutive days. Participants' Braden score, Elderly Mobility Scale (EMS) score, Movement Level, and 6-item Cognitive Impairment Test score were assessed. Further, the sacrum and heels were assessed daily using a non-invasive subepidermal moisture (SEM) scanner and visual skin assessment (VSA). SEM values > 0.5 were considered as indicative of the presence of an SEM-PU.

RESULTS

The incidence rate of VSA-PU was 15.1% (N = 8). There was an incidence of 87.5% (N = 42) of SEM-PU damage. According to the Braden subscale, Mobility Braden, most of the participants (62.2%, N = 33) were assessed as having no limitations/slightly limited mobility, while the EMS indicated that most of the participants (67.9%, N = 36) were classed in an independent category. From the 42 SEM-PUs observed, 62% (N = 26) occurred among the low movers, and 38% (N = 16) occurred among the high movers.

LINKING EVIDENCE TO ACTION

Using traditional methods for the assessment of movement does not provide insight into the protective nature of the movement. Given that both low- and high-moving patients can develop tissue damage, it is important to focus on the assessment of movement using more objective measures and algorithms, which enable real-time assessment of the protective nature of the movement. This would enable development of person-centered PU prevention strategies to reduce the burden of this significant healthcare problem.

Clinical profile of the SEM Scanner - Modernizing pressure injury care pathways using Sub-Epidermal Moisture (SEM) scanning

INTRODUCTION

Pressure injuries (PIs) are a global health concern. Current PI care standards, including skin tissue assessments (STA) and health care professional (HCP) clinical judgment, diagnose visibly manifested PIs on the skin's surface, i.e. after the damage has already occurred. However, objective assessment of early-stage, non-visible, pressure-induced tissue damage is clinically impossible within the current standard of care. The SEM Scanner is the first device authorized by the Food and Drug Administration (FDA) that addresses this unmet clinical need.

AREAS COVERED

This review describes the novel sub-epidermal moisture (SEM) scanning technology of the device and summarizes the clinical safety and efficacy data that support the use of the scanner in routine PI care practice.

EXPERT OPINION

The clinical strategy for developing the SEM Scanner is noteworthy. SEM technology using anatomy-specific data enables HCPs to provide early PI prevention interventions before visible signs of tissue damage develop while the damage is still reversible. When adopted into routine practice, the device identifies an increased risk of developing PIs 5 days (median) earlier than STA. FDA clearance was based on bench studies and data from three foundational trials that demonstrate the diagnostic accuracy of the device algorithm significantly exceeding clinical judgment (p < 0.001).

The benefits of using a first generation SEM scanner versus an equipment selection pathway in preventing HAPUs

Several studies have demonstrated improved clinical outcomes in pressure ulcer prevention using the SEM scanner, but none have compared it with other methods. In one of Scotland's health boards, 'hot spot' wards had been unable to reduce the number of hospital-acquired pressure ulcers (HAPUs) after several years of focused improvement work. In addition, other wards showed high use of dynamic therapy systems with associated costs. This review compares the use of a first generation SEM scanner versus a mattress and equipment selection pathway over a 6-week period. The findings show that the SEM scanner wards had zero HAPU while the equipment pathway wards developed a total of 4 HAPU. The two SEM scanner wards showed a 11% and 33% reduction in dynamic therapy use, while the pathway wards showed an average 40% increase. Consideration should be given to using SEM scanners to support staff decision-making to reduce HAPU development and dynamic therapy usage.

Exploring the Role of Pain as an Early Indicator for Individuals at Risk of Pressure Ulcer Development: A Systematic Review

BACKGROUND

Pressure ulcer (PU) development begins with an inflammatory response, arising due to pressure and shear forces causing changes to the cytoskeletal structure of cells. Thus, pain, synonymous with inflammation, may be an indicator of PU development.

AIM

To explore the role of pain as an indicator of PU development and to determine how this pain was measured.

METHOD

We searched PUBMED, CINAHL, SCOPUS, Cochrane, and EMBASE databases. A total of 879 records were returned, with eight satisfying the inclusion criteria. Narrative data synthesis was undertaken. The quality of studies was assessed using the evidence-based librarianship (EBL) checklist.

RESULTS

The studies were conducted between 2000 and 2019, and 75% (n = 6) employed a cross-sectional design. The mean sample size was 760 participants (SD = 703). Of the included studies, 87.5% (n = 7) identified that pain was associated with PU development. The most frequent pain assessment tool was the numeric rating scale (37.5%; n = 3). Using the EBL checklist, 62.5% (n = 5) of the studies scored ≥75%, reflecting validity.

LINKING EVIDENCE TO ACTION

Pain is associated with PU development; however, further research is required to validate these findings and assess the characteristics associated with pain as a symptom preceding PU development.

Evaluating the impact on hospital acquired pressure injury/ulcer incidence in a United Kingdom NHS Acute Trust from use of sub-epidermal scanning technology

BACKGROUND

The incidence of pressure injury/ulcers is persistent despite multiple prevention strategies in hospitals across the globe. Current standard of pressure injury/ulcer care supported by subjective skin tissue assessments, risk assessment tools and clinical judgement is ineffective in consistent pressure injury/ulcer prevention.

AIM

A pragmatic study, aligning with SQUIRE guidelines, was conducted at Chelsea and Westminster hospitals to measure the impact of adding scanning technology to the prevailing standard of care pathway on the incidence of category 2-4 hospital-acquired pressure injury/ulcers.

METHODS

Six hundred and ninety-seven mixed-population patients at risk for pressure injuries/ulcers with a Waterlow score of ≥10 and a mean age ≥65 years were enrolled across four wards over a 6-month period. Scanning technology was added to the prevailing standard of care as a device adjunctive to clinical judgement for the detection of deep and early-stage pressure-induced tissue damage. Ward staff completed comprehensive device training by the device manufacturer. Clinical interventions were initiated by clinical judgement informed by injury/ulcer risk assessments, skin and tissue assessments and scanner readings. Incidence of reportable category 2-4 pressure injuries/ulcers from the prior 12-month period from the same wards were used as a control comparator population. All diagnosed category 2-4 pressure injuries/ulcers, unstageable and deep-tissue injuries were recorded.

RESULTS

Prior study 12-month pressure injury/ulcer incidence was 0.6% (5/892 patients) in ward A, 4.4% (9/206 patients) in Ward B, 1.1% (12/1,123 patients) in Ward C and 2.6% (16/625 patients) in Ward D. Two pressure injury/ulcers in Ward B were recorded during the study. Zero pressure injuries/ulcers were recorded in the remaining three wards resulting in an 81% incidence reduction across all four wards. Improved clinical decisions from clinical judgement based on Sub-Epidermal Moisture (SEM) Scanner data were reported in 83% patients (n=578/697).

CONCLUSION

Implementing scanning technology into routine clinical practice achieves consistent reductions in pressure injury/ulcer incidence.

Fresh Perspectives on Hospital-Acquired Neonatal Skin Injury Period Prevalence From a Multicenter Study: Length of Stay, Acuity, and Incomplete Course of Antenatal Steroids

The objective of this study was to explore neonatal skin injury period prevalence, classification, and risk factors. Skin injury period prevalence over 9 months and χ2, Mann-Whitney U, and independent-samples t tests compared injured and noninjured neonates, with P values less than .05 considered statistically significant. Injury prediction models were developed using Classification and Regression Tree (CART) analysis for the entire cohort and separately for those classified as high or low acuity. The study took place in 3 Australian and New Zealand units. Neonates enrolled (N = 501) had a mean birth gestational age of 33.48 ± 4.61 weeks and weight of 2138.81 ± 998.92 g. Of the 501 enrolled neonates, 206 sustained skin injuries (41.1%), resulting in 391 injuries to the feet (16.4%; n = 64), cheek (12.5%; n = 49), and nose (11.3%; n = 44). Medical devices were directly associated with 61.4% (n = 240) of injuries; of these medical devices, 50.0% (n = 120) were unable to be repositioned and remained in a fixed position for treatment duration. The strongest predictor of skin injury was birth gestation of 30 weeks or less, followed by length of stay of more than 12 days, and birth weight of less than 1255 g. Prediction for injury based on illness acuity identified neonates less than 30 weeks' gestation and length of stay more than 39 days were at a greater risk (high acuity), as well as neonates less than 33 weeks' gestation and length of stay of more than 9 days (low acuity). More than 40% of hospitalized neonates acquired skin injury, of which the majority skin injuries were associated with medical devices required to sustain life. Increased neonatal clinician education and improved skin injury frameworks, informed by neonatal epidemiological data, are vital for the development of effective prevention strategies.

Clinical impact of a sub-epidermal moisture scanner: what is the real-world use?

OBJECTIVE

The presence of sub-epidermal moisture (SEM) over a bony prominence is indicative of incipient pressure ulcer (pressure injury/decubitus/bedsore) (PU). Early identification of patients at increased risk of PU can prompt interventions that reduce the incidence and severity of hospital (or community)-acquired PUs (HAPUs). This study evaluated the clinical utility of a SEM Scanner device in HAPU management.

METHOD

The study used a pragmatic 'real-world' approach. HAPU data before and during SEM Scanner use were obtained through routine audit. Patients had regular visual and daily SEM Scanner skin assessments over the sacrum and heels. Nursing care otherwise followed standard of care according to the established protocols of individual participating sites. HAPU incidence rates were determined and feedback gathered from health professionals on how the device influenced HAPU-related clinical decision-making.

RESULTS

There were 15 participating sites: 13 acute care, one palliative care and one community care setting. The sample size was 1478 patients. All sites reported a substantial reduction in mean HAPU incidence: 87.2% in acute care settings; 46.7% in the palliative care setting and 26.7% in the community care setting. A 100% incidence reduction was reported in 10 (66.7%) sites. In the palliative care setting, SEM Scanner results changed HAPU-related clinical decision-making for 40% of patients scanned. The community care site demonstrated a 82% change in clinical decision-making.

CONCLUSION

In this study, SEM analysis fitted seamlessly into routine skin assessment and enabled early identification of increased risk of tissue damage, with clinically important reductions in the incidence of HAPU across all participating sites.

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.

Anatomical variability of sub-epidermal moisture and its clinical implications

BACKGROUND

Technologies have been developed to monitor changes in dermal oedema, indicative of the early signs of pressure ulcers. However, there is limited information on the effects of regional differences in tissue morphology on these sub-epidermal moisture (SEM) parameters. This study was designed to investigate the absolute SEM readings across different anatomical sites using a commercial device.

METHODS

Twenty-four healthy participants were recruited to evaluate basal SEM values at different bony prominences, sampled by an experienced operator.

RESULTS

Distinct differences were observed in unloaded SEM values across different anatomical sites, notably between the upper and lower extremities. A high degree of variability was observed in particular sites, such as the heels. Moreover, SEM values at certain locations revealed significant relationships with age, BMI and gender (p < 0.05).

CONCLUSION

The study revealed a high level of variability between and within anatomical sites in a healthy cohort of participants. Determining the changes in local skin and sub-dermal tissue status using SEM may require consideration of both site specific and individual demographic factors, with further research needed in cohorts at risk of pressure ulcers.

Sub-epidermal moisture measurement: an evidence-based approach to the assessment for early evidence of pressure ulcer presence

This paper aims to discuss the literature pertaining to early pressure-shear induced tissue damage detection, with emphasis on sub-epidermal moisture measurement (SEM). The current method for pressure detection is visual skin assessment (VSA); however, this method is fraught with challenges. Advances in early detection of pressure ulcers are reported in the literature and mainly involve measuring inflammation markers on weight-bearing anatomical areas in order to capture the first signs of tissue damage. One novel technique currently in use is SEM measurement. This biophysical marker is the product of plasma that leaks as a response to local inflammation arising due to pressure-shear induced damage over bony prominences. The early detection of tissue damage is beneficial in two different ways. First, it enables early intervention when the damage is still microscopic and reversible and, therefore, has the potential to prevent further aggravation of healthy surrounding tissue. This arises by avoiding the causation of the problem and stopping the knock-on effect of inflammation, especially when the rapid pressure ulceration pathway of deformation is in place. Second, when the slow ischaemic-reperfusion related mechanism is undergoing, cell death can be avoided when the problem is identified before the cell reaches the "death threshold," completely averting a pressure ulcer.

A blinded clinical study using a subepidermal moisture biocapacitance measurement device for early detection of pressure injuries

This study aimed to evaluate the sensitivity and specificity of subepidermal moisture (SEM), a biomarker employed for early detection of pressure injuries (PI), compared to the "Gold Standard" of clinical skin and tissue assessment (STA), and to characterize the timing of SEM changes relative to the diagnosis of a PI. This blinded, longitudinal, prospective clinical study enrolled 189 patients (n = 182 in intent-to-treat [ITT]) at acute and post-acute sites (9 USA, 3 UK). Data were collected from patients' heels and sacrums using a biocapacitance measurement device beginning at admission and continuing for a minimum of 6 days to: (a) the patient developing a PI, (b) discharge from care, or (c) a maximum of 21 days. Standard of care clinical interventions prevailed, uninterrupted. Principal investigators oversaw the study at each site. Blinded Generalists gathered SEM data, and blinded Specialists diagnosed the presence or absence of PIs. Of the ITT population, 26.4% developed a PI during the study; 66.7% classified as Stage 1 injuries, 23% deep tissue injuries, the remaining being Stage 2 or Unstageable. Sensitivity was 87.5% (95% CI: 74.8%-95.3%) and specificity was 32.9% (95% CI: 28.3%-37.8%). Area under the receiver operating characteristic curve (AUC) was 0.6713 (95% CI 0.5969-0.7457, P < .001). SEM changes were observed 4.7 (± 2.4 days) earlier than diagnosis of a PI via STA alone. Latency between the SEM biomarker and later onset of a PI, in combination with standard of care interventions administered to at-risk patients, may have confounded specificity. Aggregate SEM sensitivity and specificity and 67.13% AUC exceeded that of clinical judgment alone. While acknowledging specificity limitations, these data suggest that SEM biocapacitance measures can complement STAs, facilitate earlier identification of the risk of specific anatomies developing PIs, and inform earlier anatomy-specific intervention decisions than STAs alone. Future work should include cost-consequence analyses of SEM informed interventions.

Utility of a sensor-based technology to assist in the prevention of pressure ulcers: A clinical comparison

Detection of subcutaneous tissue damage before it is visible can trigger early intervention and decrease hospital-acquired pressure ulcer (HAPU) rates. The objective of this two-phase study was to evaluate the clinical utility of the Sub-Epidermal Moisture (SEM) Scanner (Bruin Biometrics (BBI), LLC), a hand-held device that assesses increases in interstitial fluid or subepidermal moisture, indicating early tissue damage. Phase 1: Patients were provided standard-of-care risk assessment and interventions and were scanned with the SEM Scanner, but the resulting SEM scores were not used to determine interventions. This gave a baseline pressure ulcer incidence rate. Phase 2: This phase is the same as Phase 1 except the resulting SEM scores were used in conjunction with risk assessment scores to determine appropriate interventions and care planning. In Phase 1, 12 of the 89 subjects or 13.5% developed visible pressure ulcers-4 Stage I's, 6 Stage II's, 1 Stage III, and 1 deep tissue injury. In Phase 2, 2 of the 195 subjects or 1.0% developed visible pressure ulcers-1 Stage I and 1 Stage II. Patients in Phase 2 were more incontinent, less mobile, and had longer lengths of stay than those in Phase 1. Use of the Scanner resulted in a 93% decrease in HAPU. No deep injuries developed in Phase 2.