Biomarkers for the early detection of pressure injury: A systematic review and meta-analysis

Nursing students' perceptions and experiences in pressure injury risk assessment: A qualitative study

AIM

This study aims to capture the perspectives of senior undergraduate nursing students concerning pressure injury risk assessment, shedding light on their practical experiences and insights.

BACKGROUND

Pressure injuries pose a significant challenge in healthcare, demanding vigilant attention from healthcare professionals. Central to mitigating this challenge is the imperative role of risk assessment, placing nurses at the forefront of prevention strategies. Given the critical nature of this responsibility, the need for a robust and well-structured integration of risk assessment teaching within undergraduate nursing education becomes increasingly apparent.

DESIGN

This study was conducted as a descriptive qualitative study.

METHOD

This research was conducted at the Nursing Faculty of a State University in Ankara/Turkey, involving 19 senior students enrolled in the nursing program. Data was collected online using in-depth interviews with semi-structured interview questions between November and December 2022. After data collection, transcripts were generated and subjected to thematic analysis. The study was reported following the COREQ Checklist.

RESULTS

The study revealed two overarching themes: Opinions and Experiences. Within the Opinions theme, subthemes emerged, including "Features of Teaching," "Pressure Injury Definition," and "Improving Teaching Methods." The Experiences theme encompassed sub-themes such as the "Limited Relationship between Theoretical Teaching and Clinical Practice" and "Assessing the Risk of Pressure Injury in Practice."

CONCLUSION

Participants affirmed that theoretical instruction sufficiently addressed pressure injury risk assessment yet expressed concerns about the inadequacy of clinical teaching. Additionally, they underscored the need for innovative teaching methods in the theoretical instructional process.

The use of a protein network analysis to explore the complexity of early skin inflammation after oronasal mask application- A pilot study

Medical devices, such as non-invasive ventilation masks, save lives in health care settings but can be a cause of tissue injuries due to the pressure and shear loads on skin and soft tissue. These pressure injuries could be painful for the individual and cause a significant economic impact on healthcare providers. In the etiology of device related pressure ulcers, inflammation plays an important role. However, the exact nature and timing of inflammatory biomarker upregulation is still unknown in the early stages of skin damage. This study aimed to explore the inflammatory profile of vulnerable skin sites following non-invasive mask application on a convenience sample of eleven hospital patients. Seventy-one inflammatory proteins were explored from sebum sampled at the skin surface after oronasal mask application. A multivariate analysis to investigate differences between loaded and control site was conducted, with a protein network analysis used to explore interactions in the early inflammation. The study revealed that 21 cytokines and chemokines were important for the separation between loaded and control site. These proteins were associated with remodeling of tissue, vascular wound healing and/or cell death.

Development and validation of meta-measurement instruments: A methodological approach

A valid and reliable nursing assessment is essential for identifying required care and ensuring patient safety. The convenience of conducting a comprehensive assessment of the patient has led to a significant increase in assessment tools that may slow down the process. Nevertheless, the possibility of consolidating various instruments that measure common or similar constructs into a meta-instrument is considered an alternative that could enhance assessment efficiency. A meta-instrument can be defined as a measurement tool that consolidates other instruments based on measuring related constructs and sharing dimensions or items, aiming to achieve a more parsimonious measurement. Literature on such assessment tools is scarce, and there are numerous options for their construction and initial validation. Additionally, it is advisable to confirm their psychometric properties and ensure that they maintain, at the very least, the same diagnostic capacity as the original instruments. This article presents a proposal for the phases to follow in constructing meta-instruments, along with various methodological alternatives that can be employed based on the characteristics of the original instruments and the purpose of creating the meta-instrument. Furthermore, special attention is given to the checklists that should be used to study the psychometric properties and diagnostic capacity of the meta-instruments. Finally, future lines of research and challenges in the development of nursing assessment meta-instruments are discussed.

Knowledge and attitudes regarding pressure injuries among assistant nurses in a clinical context

This study aimed to evaluate assistant nurses' knowledge of and attitudes towards pressure injuries in a clinical setting. It employed a cross-sectional design, using two validated surveys: PUKAT 2.0 and APUP, alongside open-ended questions. A convenience sample of 88 assistant nurses from five wards across two departments at a 600-bed university hospital in Sweden participated. Participants answered the questionnaire and open-ended questions, followed by a learning seminar led by the study leader covering PUKAT 2.0 knowledge questions. The seminar ended with an evaluation of this training approach. Results revealed a significant knowledge gap in pressure injury prevention among assistant nurses, with a mean PUKAT 2.0 knowledge score of 33.8 and a standard deviation of ±11.7 (a score of 60 is deemed satisfactory). Only 3.4% (n = 3) of participants achieved a satisfactory knowledge score. However, attitudes towards pressure injury prevention, assessed by the APUP tool, were generally positive among the majority of the participants. Open-ended questions and evaluations of the seminar showed assistant nurses' desire for pressure injury prevention training and their appreciation for the seminar format. Further studies need to evaluate recurrent training procedures and departmental strategies aimed at reducing the knowledge gap among healthcare staff.

A machine learning algorithm-based predictive model for pressure injury risk in emergency patients: A prospective cohort study

OBJECTIVES

To construct pressure injury risk prediction models for emergency patients based on different machine learning algorithms, to optimize the best model, and to provide a suitable assessment tool for preventing the occurrence of pressure injuries in emergency patients.

METHODS

A convenience sampling was used to select 312 patients admitted to the emergency department of a tertiary care hospital in Tianjin, China, from May 2022 to March 2023, and the patients were divided into a modeling group (n = 218) and a validation group (n = 94) in a 7:3 ratio. Based on the results of one-factor logistic regression analysis in the modeling group, three machine learning models, namely, logistic regression, decision tree, and neural network, were used to establish a prediction model for pressure injury in emergency patients and compare their prediction effects. The optimal model was selected for external validation of the model.

RESULTS

The incidence of pressure injuries in emergency patients was 8.97 %, 64.52 % of pressure injuries occurred in the sacrococcygeal region, and 64.52 % were staged as stage 1. Serum albumin level, incontinence, perception, and mobility were independent risk factors for pressure injuries in emergency patients (P < 0.05), and the area under the ROC curve of the three models was 0.944-0.959, sensitivity was 91.8-95.5 %, specificity was 72.2-90.9 %, and the Yoden index was 0.677-0.802; the decision tree was the best model that The area under the ROC curve for the validation group was 0.866 (95 % CI: 0.688-1.000), with a sensitivity of 89.8 %, a specificity of 83.3 %, and a Yoden index of 0.731.

CONCLUSIONS

The decision tree model has the best predictive efficacy and is suitable for individualized risk prediction of pressure injuries in emergency medicine specialties, which provides a reference for the prevention and early intervention of pressure injuries in emergency patients.

Aging of Superficial Musculoaponeurotic System of the Face-Novel Biomarkers and Micro-CT Relevance of Facial Anti-Gravity Support

The soft superficial tissues of the face are against gravity through an intricate network of ligaments and ligamentous attachments. The aim of this investigation is to delineate the relationship between the muscular, fibrous, and vascular components of the superficial musculoaponeurotic system of the face (SMAS) at the level of its periosteal fixation areas from advanced radiological and novel biomarkers' perspectives. These areas represent key points underlying skin aging and the longevity of restorative surgery results. Methods: This study was carried out on 37 surgical specimens, excised from patients admitted for surgery. On the excised specimens, we used special immunohistochemical techniques, such as markers for collagen type III, angiogenesis, vascular endothelium (I-CAM2) and muscle fibers (MYH2). We performed a micro-CT evaluation of these 37 specimens. Results: The results of this study showed different radiologic and IHC characteristics of the means of periosteal fixation of the SMAS. Evidence of morphohistological and radiological peculiarities of the retaining ligaments highlights new data for future functional studies of these structures. Our research must be continued with larger groups of subjects and through detailed methodological studies of vascular microperfusion and could represent an important new step in biotissue engineering and the customization of surgical techniques involving the sub-SMAS layers.

Comparison of the predictive validity of the Braden and Waterlow scales in intensive care unit patients: A multicentre study

BACKGROUND

The first step in preventing pressure injuries (PIs), which represent a significant burden on intensive care unit (ICU) patients and the health care system, is to assess the risk for developing PIs. A valid risk assessment scale is essential to evaluate the risk and avoid PIs.

OBJECTIVES

To compare the predictive validity of the Braden scale and Waterlow scale in ICUs.

DESIGN

A multicentre, prospective and cross-sectional study.

METHODS

We conducted this study among 6416 patients admitted to ICUs in Gansu province of China from April 2021 to October 2022. The incidence and characteristics of PIs were collected. The risk assessment of PIs was determined using the Braden and Waterlow scale. The sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve of the two scales were compared.

RESULTS

Out of 5903 patients, 72 (1.2%) developed PIs. The sensitivity, specificity, positive and negative predictive, and the area under the curve of the Braden scale were 77.8%, 50.9%, 0.014 and 0.996, and 0.689, respectively. These values for the Waterlow scale were 54.2%, 71.1%, 0.017, 0.994 and 0.651.

CONCLUSIONS

Both scales could be used for risk assessment of PIs in ICU patients. However, the accuracy of visual inspection for assessment of skin colour, nursing preventive measures for patients and scales inter-rater inconsistency may limited the predictive validity statistics.

RELEVANCE TO CLINICAL PRACTICE

Both scales could be used for PIs risk assessment. The low specificity of the Braden scale and low sensitivity of the Waterlow scale remind medical staff to use them in combination with clinical judgement and other objective indicators.

PATIENT OR PUBLIC CONTRIBUTION

This study was designed to enhance the management of PIs. Patients and the general public were not involved in the study design, analysis, and interpretation of the data or manuscript preparation.

Risk factors predicting hospital-acquired pressure injury in adult patients: An overview of reviews

BACKGROUND

Hospital-acquired pressure injuries remain a significant patient safety threat. Current well-known pressure injury risk assessment tools have many limitations and therefore do not accurately predict the risk of pressure injury development over diverse populations. A contemporary understanding of the risk factors predicting pressure injury in adult hospitalised patients will inform pressure injury prevention and future researchers considering risk assessment tool development may benefit from our summary and synthesis of risk factors.

OBJECTIVE

To summarise and synthesise systematic reviews that identify risk factors for hospital-acquired pressure injury development in adult patients.

DESIGN

An overview of systematic reviews.

METHODS

Cochrane and the Joanna Briggs Institute methodologies guided this overview. The Cochrane library, CINAHL, MEDLINE, and Embase databases were searched for relevant articles published in English from January 2008 to September 2022. Two researchers independently screened articles against the predefined inclusion and exclusion criteria, extracted data and assessed the quality of the included reviews using "a measurement tool to assess systematic reviews" (AMSTAR version 2). Data were categorised using an inductive approach and synthesised according to the recent pressure injury conceptual frameworks.

RESULTS

From 11 eligible reviews, 37 risk factors were categorised inductively into 14 groups of risk factors. From these, six groups were classified into two domains: four to mechanical boundary conditions and two to susceptibility and tolerance of the individual. The remaining eight groups were evident across both domains. Four main risk factors, including diabetes, length of surgery or intensive care unit stay, vasopressor use, and low haemoglobin level were synthesised. The overall quality of the included reviews was low in five studies (45 %) and critically low in six studies (55 %).

CONCLUSIONS

Our findings highlighted the limitations in the methodological quality of the included reviews that may have influenced our results regarding risk factors. Current risk assessment tools and conceptual frameworks do not fully explain the complex and changing interactions amongst risk factors. This may warrant the need for more high-quality research, such as cohort studies, focussing on predicting hospital-acquired pressure injury in adult patients, to reconsider these risk factors we synthesised.

REGISTRATION

This overview was registered with the PROSPERO (CRD42022362218) on 27 September 2022.

Effect of e-learning program for improving nurse knowledge and practice towards managing pressure injuries: A systematic review and meta-analysis

AIM

The aim of this review was to determine the effectiveness of the e-learning programs for improving the knowledge and professional practices of nursing personnel in managing pressure injuries patients.

DESIGN

Systematic review and meta-analysis.

METHODS

Systematic search was done in EMBASE, SCOPUS, Cochrane library, MEDLINE, Google Scholar, ScienceDirect and Clinicaltrials.gov databases until August 2022. Meta-analysis was carried out using random-effects model, and the results were reported as pooled standardized mean differences (SMD), or odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

Eight studies were included in the analysis. Most of the studies had higher risk of bias. The pooled SMD for knowledge score and for the classification skill were 1.40 (95%CI: 0.45-2.35; I2  = 93.1%) and 1.75 (95%CI: 0.94-3.24; I2  = 78.3%) respectively. The pooled OR for the classification skills was 1.75 (95%CI: 0.94-3.24; I2  = 78.3%).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Characteristics and risk factors of facial pressure injuries in acute inpatients using noninvasive positive pressure ventilation: A retrospective case control study

OBJECTIVE

To explore the characteristics and risk factors of facial pressure injuries in patients using noninvasive positive pressure ventilation.

SETTING AND SAMPLE

Patients who developed facial pressure injuries due to non-invasive positive pressure ventilation at a teaching hospital in Taiwan from January 2016 to December 2021 were selected, resulting in a total of 108 patients in our case group. A control group was formed by matching each case by age and gender to three acute inpatients who had used non-invasive ventilation but had not developed facial pressure injuries, resulting in 324 patients in the control group.

RESEARCH METHODOLOGY

This study was a retrospective case-control study. The characteristics of the patients who developed pressure injuries at different stages in the case group were compared, and the risk factors of non-invasive ventilation-related facial pressure injuries were then determined.

RESULTS

Higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale score, and lower albumin levels in the former group. The results of multivariate analysis from binary logistic regression involving the duration of non-invasive ventilation usage demonstrated that the patients who used this device for 4-9 days and 16 days were at greater risk of facial pressure injuries than those who used it for 3 days; in terms of the Braden scale score, higher Braden scale scores were correlated with a higher risk of facial pressure injuries. In addition, albumin levels lower than the normal range were correlated with a higher risk of facial pressure injuries.

CONCLUSION

Patients with pressure injuries at higher stages had a higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale scores, and lower albumin levels. Thus, a longer duration of non-invasive ventilation use, lower Braden scale scores, and lower albumin levels were also risk factors for non-invasive ventilation-related facial pressure injuries.

IMPLICATIONS FOR CLINICAL PRACTICE

Our results serve as a useful reference for hospitals, both in creating training programs for their medical teams to prevent and treat facial pressure injuries and in drafting guidelines for assessing risk in order to prevent facial pressure injuries caused by non-invasive ventilation. The duration of device usage, Braden scale scores, and albumin levels in particular should be seriously monitored to reduce the occurrence of facial pressure injuries in acute inpatients treated with non-invasive ventilation.

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

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

Systematic Review for Risks of Pressure Injury and Prediction Models Using Machine Learning Algorithms

Pressure injuries are increasing worldwide, and there has been no significant improvement in preventing them. This study is aimed at reviewing and evaluating the studies related to the prediction model to identify the risks of pressure injuries in adult hospitalized patients using machine learning algorithms. In addition, it provides evidence that the prediction models identified the risks of pressure injuries earlier. The systematic review has been utilized to review the articles that discussed constructing a prediction model of pressure injuries using machine learning in hospitalized adult patients. The search was conducted in the databases Cumulative Index to Nursing and Allied Health Literature (CINAHIL), PubMed, Science Direct, the Institute of Electrical and Electronics Engineers (IEEE), Cochrane, and Google Scholar. The inclusion criteria included studies constructing a prediction model for adult hospitalized patients. Twenty-seven articles were included in the study. The defects in the current method of identifying risks of pressure injury led health scientists and nursing leaders to look for a new methodology that helps identify all risk factors and predict pressure injury earlier, before the skin changes or harms the patients. The paper critically analyzes the current prediction models and guides future directions and motivations.

Nurses' and nursing students' knowledge and attitudes to pressure injury prevention: A meta-analysis based on APUP and PUKAT

BACKGROUND

Morbidity and mortality among patients due to pressure injuries continue to rise. Nurses play a critical role in preventing pressure injuries. However, published results on nurses' knowledge and attitudes for pressure injury prevention are often contradictory.

OBJECTIVES

To conduct a meta-analysis of nurses' and nursing students' knowledge and attitudes toward pressure injury prevention.

DESIGN

A meta-analysis of cross-sectional studies.

DATA SOURCES

Ten databases were queried for the meta-analysis. The search period was from the time of the databases' establishment to February 2023.

REVIEW METHODS

This review followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The Agency for Healthcare Research and Quality (AHRQ) was used to assess the methodological quality of the included studies. Statistical analysis was conducted with the Stata 15.0 software, and the quantitative data of knowledge and attitude toward preventing PI in all studies were summarized.

RESULTS

Thirteen studies from 9 countries were included. The meta-analysis showed that nurses and nursing students had low knowledge but positive attitudes toward pressure injury prevention. Subgroup analysis showed that the pooled proportion of both knowledge and attitudes was higher in Asia than in Europe. Nurses had higher knowledge than nursing students, however, the former had a more negative attitude than the latter. Sensitivity analyses were robust. Egger's test showed no significant publication bias.

CONCLUSION

The knowledge of nurses and nursing students about pressure injury prevention is not promising and there is an urgent need for continuous learning. Attitudes are more positive but there is room for improvement. The relevant departments should strengthen nurses' and nursing students' knowledge of pressure injury prevention and further improve their attitudes toward pressure injury prevention.

Closure of pressure injury and mortality in internal medicine wards

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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