Suspected Deep Tissue Injury Profile: A Pilot Study

Use of a Shear Reduction Surface for Prehospital Transport: A Randomized Crossover Study

OBJECTIVE

To compare the effectiveness of an antishear mattress overlay (ASMO) with a standard ambulance stretcher surface in reducing pressure and shear and increasing patient comfort.

METHODS

In this randomized, crossover design, adults in three body mass index categories served as their own controls. Pressure/shear sensors were applied to the sacrum, ischial tuberosity, and heel. The stretcher was placed in sequential 0°, 15°, and 30° head-of-bed elevations with and without an ASMO. The ambulance traveled a closed course, achieving 30 mph, with five stops at each head-of-bed elevation. Participants rated discomfort after each series of five runs.

RESULTS

Thirty individuals participated. Each participant had 30 runs (15 with an ASMO, 15 without), for a total of 900 trial runs. The peak-to-peak shear difference between support surfaces was -0.03 N, indicating that after adjustment for elevation, sensor location, and body mass index, peak shear levels at baseline (starting pause) were 0.03 N lower for the ASMO than for the standard surface ( P = .02). The peak-to-peak pressure difference between surfaces was -0.16 mm Hg, indicating that prerun peak-to-peak pressure was 0.16 mm Hg lower with the ASMO versus standard surface ( P = .002). The heel received the most pressure and shear. Discomfort score distributions differed between surfaces at 0° ( P = .004) and 30° ( P = .01); the overall score across all elevations was significantly higher with the standard surface than with the ASMO ( P = .046).

CONCLUSIONS

The ASMO reduced shear, pressure, and discomfort. During transport, the ambulance team should provide additional heel offloading.

Risk Factors Associated With Pressure Injury in Critically Ill Children With Congenital Heart Disease

BACKGROUND

Children with congenital heart disease have unique risk factors associated with the pathophysiology of an abnormal heart; hence, this population is most likely at increased risk of acquiring a pressure injury during hospitalization. Few studies have included patients with congenital heart disease or examined the factors unique to these patients.

OBJECTIVE

To identify risk factors associated with pressure injury development in children with congenital heart disease.

METHODS

This retrospective study used a convenience sample from hospital-acquired data at an urban, tertiary, free-standing children's hospital. Patients were admitted to the intensive care unit between 2011 and 2018 with a diagnosis of congenital heart disease. Chi-square analysis was done to compare risk factors between patients, and logistic regression analysis was used to predict the probability that a patient would acquire a pressure injury.

RESULTS

Eighty-two (30.5%) of the 269 patients in this study acquired pressure injuries. Sixty-six patients with pressure injuries met the inclusion criteria for analysis; 82% of those patients had had corticosteroids prescribed, and 71% were receiving anticoagulants. The overall predictive model for acquiring a pressure injury indicated an odds ratio of 3.25 (95% CI, 1.58-6.65) with an anticoagulant and an odds ratio of 9.98 (95% CI, 4.68-21.3) with a prescribed corticosteroid (P < .001 for both factors). Inpatient mortality was significantly associated with pressure injuries.

CONCLUSIONS

Corticosteroid and anticoagulant use were contributing factors in the development of pressure injuries in children with congenital heart disease.

Incidence and Characteristics of Suspected Deep Tissue Pressure Injuries on the Foot and Ankle: A Retrospective Study

PURPOSE

The purpose of this study was to measure the incidence of suspected deep tissue pressure injuries (DTPIs) in patients admitted to the hospital, describe their location, identify the related hospital length of stay, and explore any associations between intrinsic or extrinsic factors relevant to DTPI development.

DESIGN

Retrospective review/audit of clinical data.

SUBJECTS AND SETTING

We reviewed pertinent medical data from patients reported as developing a suspected deep tissue injury during hospital admission from January 2018 to March 2020. The study setting was a large tertiary public health service in Victoria, Australia.

METHODS

Patients who developed a suspected deep tissue injury during hospital admission between January 2018 and March 2020 were identified through the hospital online risk recording system. Data were extracted from the relevant health records, including demographics, admission data, and pressure injury data. The incidence rate was expressed per 1000 patient admissions. Multiple regression analyses were used to determine associations between the time (days) to develop a suspected deep tissue injury and intrinsic (patient level) or extrinsic (hospital level) factors.

RESULTS

Six hundred fifty-one pressure injuries were recorded during the audit period. A minority (9.5%; n = 62) of patients developed a suspected deep tissue injury; all were located on the foot and ankle. The incidence of suspected deep tissue injuries was 0.18 per 1000 patient admissions. The mean length of stay among patients who developed a DTPI was 59.0 (SD = 51.9) days as compared to a mean of 4.2 (SD = 11.8) days for all patients admitted to the hospital during this period. Multivariate regression analysis determined that the longer time (in days) to develop a pressure injury was associated with having a higher body weight (Coef = 0.02; 95% CI = 0.00 to 0.04; P = .043), not having off-loading (Coef =-3.63; 95% CI =-6.99 to -0.27; P = .034), and an increasing number of ward transfers (Coef = 0.46; 95% CI = 0.20 to 0.72; P = .001).

CONCLUSIONS

Findings identified factors that may play a role in the development of suspected deep tissue injuries. A review of risk stratification in health services may be beneficial, with consideration to adjustments of procedural assessments of patients at risk.

Risk factors for the development and evolution of deep tissue injuries: A systematic review

AIMS

The aim of this systematic review is to identify the current epidemiological evidence indicating the unique risk factors for deep tissue injury (DTI) compared to grade I-IV pressure injury (PI), the proportion of DTI which evolve rather than resolve and the anatomical distribution of DTI.

METHODS

A systematic literature search was undertaken using the MEDLINE and CINAHL Plus databases using the search terms 'Deep tissue injury OR DTI [Title/abstract]'. A google scholar search was also conducted in addition to hand searches of relevant journals, websites and books which were identified from reference lists in retrieved articles. Only peer-reviewed English language articles published 2009-2021 were included, with full text available online.

RESULTS

The final qualitative analysis included nine articles. These included n = 4 retrospective studies, n = 4 prospective studies and n = 1 animal study.

CONCLUSION

The literature indicates that the majority of DTI occur at the heel and sacrum although in paediatric patients they are mainly associated with medical devices. Most DTI are reported to resolve, with between 9.3 and 27% deteriorating to full thickness tissue loss. Risk factors unique to DTI appear to include anaemia, vasopressor use, haemodialysis and nicotine use although it is unclear if these factors are unique to DTI or are shared with grade I-IV PI. Factors associated with deterioration include cooler skin measured using infrared thermography and negative capillary refill. With 100% of DTI showing positive capillary refill in one study resolving without tissue loss (p = 0.02) suggesting this may be an effective prognostic indicator. More prospective studies are required focusing on establishing causal links between risk factors identified in earlier retrospective studies. Ideally these should use statistically powered samples and sufficient follow up periods allowing DTI outcomes to be reached. Further work is also needed to establish reliable diagnostic criteria for DTI in addition to more studies in the paediatric population.

A novel mathematical model including the wetness parameter as a variable for prevention of pressure ulcers

Pressure ulcers are injuries caused by external conditions such as pressure, friction, shear, and humidity resulting from staying in the same position for a long time in bedridden patients. It is a serious problem worldwide when assessed in terms of hospital capacity, nursing staff employment and treatment costs. In this study, we developed a novel mathematical model based on one of our previous models to prevent pressure ulcers or delay injuries. The proposed model uses a human thermal model that includes skin temperature, hypothalamus temperature, regional perspiration coefficient, and unconsciously loss of water amount. Moreover, in our model, we defined a variable wetness parameter in addition to the parameters, pressure, temperature, and humidity. The proposed model is mathematically defined in detail and tested for a wide range of parameters to show the model's effectiveness in determining the pressure ulcer formation risk. The model is also compared with a model from the literature that based on only the general parameters, pressure, temperature, and humidity. The obtained results showed that the model determines the risk of the occurrence of the pressure ulcer more precisely than the compared one.

Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study

PURPOSE

To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs).

DESIGN

Retrospective, matched, case-control design.

SUBJECTS/SETTING

Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016.

METHODS

Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score).

RESULTS

All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization.

CONCLUSION

Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.

A Quality Improvement Project Comparing Two Treatments for Deep-Tissue Pressure Injuries to Feet and Lower Legs of Long-term Care Residents

OBJECTIVE

To retrospectively examine clinical outcomes from a feasibility study that compared two treatment options for deep-tissue pressure injuries (DTPIs), including the clinical indicators increasing the risk of deteriorating DTPIs among long-term care residents.

METHODS

A retrospective chart audit of 40 DTPIs from 33 long-term care residents in two long-term care facilities was conducted to compare (1) polymeric membrane dressings (PMDs) with offloading and (2) a skin barrier film with offloading.

RESULTS

Of the 13 DTPIs treated with PMDs, only 23% deteriorated to a stage 3 or 4 pressure injury (PI), whereas of the 27 DTPIs treated with skin barrier film, 41% deteriorated to a stage 3 or 4 PI. The clinical factors found to increase the risk of developing and deteriorating DTPIs included weight loss, hypoalbuminemia, debility, dementia, coronary artery disease, and cerebrovascular disease.

CONCLUSIONS

The PMD group's DTPIs evolved into fewer open PIs despite having higher percentages of clinical indicators for DTPIs. The project findings support the use of PMD dressings for DTPIs; however, more robust research is warranted.

Silicone Foam Dressing for Prevention of Sacral Deep Tissue Injuries Among Cardiac Surgery Patients

OBJECTIVE

To evaluate the effect of silicone foam dressings, placed preoperatively, on the incidence of postoperative sacral deep-tissue pressure injuries.

DESIGN, SETTING, AND PATIENTS

An uncontrolled before-and-after quality improvement method was used. Within a single, urban academic medical center, consecutively admitted adult cardiac surgery patients were included in the pre- and postintervention groups; only those receiving elective procedures were included.

INTERVENTION

Nurses applied a sacral silicone foam dressing preoperatively. This dressing was maintained on the patient's sacrum intraoperatively and postoperatively for up to 5 days in the intensive care and step-down units.

MAIN RESULTS

This project demonstrated a clinically significant decrease (P < .02) in the incidence of postoperative sacral deep-tissue pressure injuries from 2.3% (preintervention, n = 300) to 0% (postintervention, n = 224). These results were sustained for 24 months after the trial was completed.

CONCLUSIONS

The use of silicone foam dressings may be an effective prophylactic intervention to reduce the incidence of perioperative deep-tissue pressure injuries among cardiac surgery patients, a high-risk population.

Use of Noncontact Low-Frequency Ultrasound in Deep Tissue Pressure Injury: A Retrospective Analysis

PURPOSE

The purpose of this study was to examine the effect of noncontact low-frequency ultrasound (NLFU) on deep tissue pressure injury (DTPI), both hospital-acquired and those present on admission (POA).

DESIGN

Retrospective, descriptive study.

SAMPLE AND SETTING

Medical records from 44 adult patients with a DTPI treated with NLFU were reviewed; 22 had a hospital-acquired DTPI (HADTPI) and 22 had DTPI POA. Their mean age was 71.3 ± 16.3 years (mean ± SD); 52% were male. The study setting was a 318-bed community hospital in the Mid-Atlantic region of the United States.

METHODS

Data were collected from the medical records including demographic and relevant clinical characteristics, DTPI measurements, and DTPI evolution/resolution. Data were summarized and examined using descriptive statistics (eg, frequencies and percentages and means and standard deviations). Differences between groups were examined using paired t tests or the Mann-Whitney U test and the chi-square test as appropriate. In addition, the heel DTPI subgroup (N = 8) was examined separately due to the small sample size.

RESULTS

All patients with HADTPI and DTPI POA treated with NLFU exhibited a statistically significant decrease in injury size from initiation to discontinuation of NLFU therapy (24.6 cm vs 14.4 cm, P = .02). No statistically significant difference in wound resolution was found between HADTPI versus DTPI POA (27% vs 18%, P = .47). Mean size of both HADTPI and DTPI POA decreased significantly from 15.9 to 13.4 cm (P = .045) by NLFU therapy. Wounds were classified as resolved at completion of treatment in 23% (10 out of 44) of all treated patients. Of all patients with the potential to be resolved (not discharged early or expired) 63% (10 out of 16) had wounds classified as resolved.

CONCLUSION

Study findings suggest that NLFU is a viable and promising treatment option for both HADTPI and DTPI POA. Future studies are needed to confirm these results and to examine efficacy and feasibility of DTPI across care settings.

A MRI-Compatible Combined Mechanical Loading and MR Elastography Setup to Study Deformation-Induced Skeletal Muscle Damage in Rats

Deformation of skeletal muscle in the proximity of bony structures may lead to deep tissue injury category of pressure ulcers. Changes in mechanical properties have been proposed as a risk factor in the development of deep tissue injury and may be useful as a diagnostic tool for early detection. MRE allows for the estimation of mechanical properties of soft tissue through analysis of shear wave data. The shear waves originate from vibrations induced by an external actuator placed on the tissue surface. In this study a combined Magnetic Resonance (MR) compatible indentation and MR Elastography (MRE) setup is presented to study mechanical properties associated with deep tissue injury in rats. The proposed setup allows for MRE investigations combined with damage-inducing large strain indentation of the Tibialis Anterior muscle in the rat hind leg inside a small animal MR scanner. An alginate cast allowed proper fixation of the animal leg with anatomical perfect fit, provided boundary condition information for FEA and provided good susceptibility matching. MR Elastography data could be recorded for the Tibialis Anterior muscle prior to, during, and after indentation. A decaying shear wave with an average amplitude of approximately 2 μm propagated in the whole muscle. MRE elastograms representing local tissue shear storage modulus G_d showed significant increased mean values due to damage-inducing indentation (from 4.2 ± 0.1 kPa before to 5.1 ± 0.6 kPa after, p<0.05). The proposed setup enables controlled deformation under MRI-guidance, monitoring of the wound development by MRI, and quantification of tissue mechanical properties by MRE. We expect that improved knowledge of changes in soft tissue mechanical properties due to deep tissue injury, will provide new insights in the etiology of deep tissue injuries, skeletal muscle damage and other related muscle pathologies.

Differential diagnosis of suspected deep tissue injury

Deep tissue injury (DTI) can be difficult to diagnose because many other skin and wound problems can appear as purple skin or rapidly appearing eschar. The diagnosis of DTI begins with a thorough history to account for times of exposure to pressure, such as 'time down' at the scene or time during which the patient was flat and could not respond. Patients with light skin tones present with classic skin discolouration of purple or maroon tissue, a defined border around the area of injury, and often surrounding erythema is evident. Persistent erythema and hyperpigmentation, rather than blanching, should be used to determine pressure injury in dark skin tone patients. Differential diagnosis includes stage 2 pressure ulcers, incontinence-associated dermatitis, skin tears, bruising, haematoma, venous engorgement, arterial insufficiency, necrotising fasciitis and terminal skin ulcers. Many skin problems can also have a purple hue or rapidly developing eschar, and a working knowledge of dermatology is needed.