Pressure Ulcer Prevalence by Level of Paralysis in Patients With Spinal Cord Injury in Long-term Care

Outcomes of Pressure Sore Surgery in Patients with Spinal Cord Injury and Spasticity

Background

Spasticity is a serious complication of spinal cord injury/disease (SCI/D) that affects 60%-80% of patients with this condition. The presence of spasticity can have a significant impact on the outcomes of reconstructive surgical interventions, such as those on pressure sores (PSs). Moreover, in the conservative treatment of PSs, spasticity may prevent maintaining adequate postures to avoid skin friction or traction. The aim of this study is to describe the PS reconstruction outcomes in a cohort of patients with SCI/D affected by spasticity.

Methods

In this retrospective study of patients with SCI/D consecutively admitted to Montecatone Rehabilitation Institute between October 2013 and March 2022, 54 PSs were treated in 46 people with spasticity.

Results

Postsurgery complications occurred in 26 of 54 treated PS, of which seven were major. Eleven patients experienced more than one complication. The overall incidence of postsurgical complications was 48.1%, and the incidence of major complications was 13%. Median length of hospital stay was 3.8 versus 1.8 months. Compared with other reports in the literature of PS reconstruction in patients with SCI/D, we found higher rates of overall, minor, and major complications.

Conclusions

Spasticity proved to be an important condition to consider, and its treatment requires specialized physicians. The collaboration between plastic surgeons and spasticity specialists is crucial to define the best treatment to reduce postoperative complications.

Nurses' barriers to the pressure ulcer risk assessment scales implementation: A phenomenological study

AIM

The aim of the study was to explore nurses' barriers to the pressure ulcer risk assessment scales implementation.

DESIGN

A qualitative descriptive phenomenological study.

METHODS

The research participants comprised of 10 nurses at various medical and surgical departments in a teaching hospital northeast of Namibia. Data were collected between August and September 2022 through in-depth, semi-structured face-to-face individual interviews and analysed using Colaizzi's 7-step method.

RESULTS

The interviews with nurses, led to two major themes being discovered: (1) factors hindering the effective prevention of pressure ulcers; (2) suggestions for improvements in the utilization of risk assessment scales. The participants noted that they had inadequate knowledge of the formal risk assessment scales; there were inadequate resources and insufficient staff; there were no policies or guidelines regarding the management of pressure ulcers, all of which influenced their utilization of pressure risk assessment scales. Education and training, the provision of equipment, the hiring of new staff and the formulation of policies/guidelines would thus improve the nurses' utilization of the scales.

CONCLUSION

The findings of this study have uncovered three primary factors that have a detrimental impact on the utilization of risk assessment scales by nurses, that is their lack knowledge on pressure ulcer risk assessment scales; a shortage of staff and equipment; and an absence of policies/guidelines. The findings from this study provide valuable implications for guiding quality improvement initiatives aimed at enhancing the standard of care in Namibia and other resource-limited settings.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Multidisciplinary treatment protocol for ischiatic, sacral, trochanteric or other pressure injuries in people with spinal cord injury: a retrospective cohort study

STUDY DESIGN

Retrospective cohort study Objectives: to describe the incidence and the associated risk factors of post-surgical complications and recurrence in individuals with spinal cord injury/disorder (SCI/D) presenting deep pressure injuries (PIs), treated with a specific surgical and rehabilitation treatment protocol.

SETTING

Tertiary Rehabilitation Hospital for SCI/D in Italy.

METHODS

Retrospective analysis of the medical records of adult individuals with SCI/D, who developed a PI after the first discharge from a Spinal Unit, underwent flap surgery for PI between July 2011 and January 2018. The statistical unit of analysis was the surgical intervention. Logistic regression analysis with robust standard errors was performed to assess risk factors of post-surgical complications.

RESULTS

434 surgical intervention records were included, for a total of 378 patients. The treated PIs were ischiatic in 56.2% of the cases, sacral in 32.5%, trochanteric in 15.7%, and 5.8% were in other sites. In 239 cases (55.1%) a histological diagnosis of osteomyelitis was confirmed. Minor complications occurred in 13.6% of interventions, while major complications were 3.9%. Sacral PI (OR = 2.55, 95%CI: 1.50-4.35) and muscular/musculocutaneous flap (OR = 2.12, 95%CI: 1.05-4.28) were significant factors associated with risk of post-surgical complications. After a mean follow-up of 21 months (range 12-36), six people (1.4%) had a recurrence. Patients with a recurrence had at least one comorbidity compared to 57% of people without recurrences (p = 0.036).

CONCLUSION

Our results demonstrate that complication and recurrence rates can be minimized when an established interdisciplinary and rehabilitation protocol is integrated in the clinical management.

Continuous pressure monitoring of inpatient spinal cord injured patients: implications for pressure ulcer development

STUDY DESIGN

Cohort observational study.

OBJECTIVES

To examine the movement profiles of individuals with spinal cord injury (SCI) during their inpatient rehabilitative phase using continuous pressure monitoring (CPM), evaluating the trends in those with skin damage.

SETTING

SCI specialist rehabilitation centre in the United Kingdom.

METHODS

Individuals with SCI (n = 12) were assessed using CPM in the bed and chair over a 24-72 h. Pressure data was used as a surrogate for movement using both nursing interpretation and an intelligent algorithm. Clinical features were obtained including participants age, injury level, ASIA score, co-morbidities and prescribed support surfaces. Trends between movement profiles (frequency and intervals), SCI demographics and observed skin damage were assessed using cross-tabulation and histograms.

RESULTS

The data revealed significant correlations (p < 0.05) between the nursing observation and algorithm for predicting movement, although the algorithm was more sensitive. Individuals with high level injuries (C1-T6) were observed to have a lower frequency of movement and larger intervals between movements when compared to low level injuries (T7-L5) during both lying and sitting periods. The individuals observed to have skin damage were predominantly those who had both a low frequency of movement and extended gaps between movements.

CONCLUSIONS

Movements for pressure relief in both the bed and chair environments were dependent on the level of injury in individuals with SCI during their inpatient rehabilitation. Distinct movement patterns corresponded with those who acquired skin damage, revealing the potential clinical applications for technologies to monitor PU risk and inform personalised care.

Using Pressure Mapping to Compare Efficacy of Patient Bed Positioning Devices in Participants Who Are Able-Bodied and Those with Tetraplegia

OBJECTIVE

To compare the effectiveness of four positioning aids in able-bodied participants and those with tetraplegia, to determine (1) if devices differed with regard to pressure reduction and (2) if results differed for able-bodied participants versus those with tetraplegia.

METHODS

Forty volunteers (20 able-bodied and 20 with tetraplegia) participated. The variable of interest was reduction in mean pressure in the sacral region, measured in mm Hg. Testing was conducted in a hospital bed using a tissue-interface pressure-mapping system. Four bed positioning devices were examined in use at both 0° and 30° head-of-bed elevations: standard hospital pillows, fluidized positioners, foam wedge positioners, and polystyrene bead wedge positioners.

RESULTS

No between-group differences were found for participant type (able-bodied vs tetraplegic). However, the positioning devices tested did differ significantly in pressure reduction. Foam wedge positioners, polystyrene bead wedge positioners, and fluidized positioners all resulted in greater reduction in pressure over an area inclusive of the sacrum, ischia, and buttocks when compared with standard hospital pillows, with foam wedges performing best.

CONCLUSIONS

Better pressure reduction over the sacrum, buttocks, and ischia can be achieved when using devices specifically designed for patient positioning in bed as opposed to using standard hospital pillows. Data were not significantly different between able-bodied participants and participants with tetraplegia. Thus, pressure-mapping data examining the efficacy of bed-positioning devices using convenience sampling of able-bodied individuals can likely be generalized to apply to a population with tetraplegia as well.

Lessons learned from patients with spinal cord injury in managing pressure ulcers: A qualitative study

OBJECTIVES

To explore how individuals with spinal cord injury self-manage the prevention and treatment of pressure ulcers and to provide insight into experiences with self-management support.

DESIGN

Qualitative study using semi-structured interview and a deductive thematic analysis.

SETTING

Community.

PARTICIPANTS

Twelve of the 14 participating adults with a spinal cord injury had experience with pressure ulcers, and eight of these had a current pressure ulcer.

RESULTS

Respondents suggested to tailor treatment of pressure ulcers to patients' individual wishes and capabilities of patients. Patients and caregivers need to be aware of the importance of determining the cause of pressure ulcers to prevent deterioration. Patients often depend on informal caregivers for follow-up and prevention, and healthcare professionals in non-SCI specialties often lack the knowledge needed to manage pressure ulcers in this specific patient group. Tailored education and peer support are important for patients to set boundaries, be assertive, and cultivate a positive attitude when dealing with pressure ulcers. It is difficult to combine treatment of severe pressure ulcers and preventive measures with work roles. Managing the social impact of pressure ulcers requires more coordination with caregivers.

CONCLUSIONS

To support self-management of pressure ulcers in patients with a spinal cord injury, they must find out which preventive measures and treatments suit them best. Healthcare professionals play an important role in the self-management of pressure ulcers and can help patients deal with the emotional and social impact of pressure ulcers. To know patient's needs and tailor their education, healthcare professionals of non SCI organizations need to have knowledge of pressure ulcers management of this specific patient group.

Challenges of Patients with Spinal Cord Injury During the COVID-19 Pandemic: A Qualitative Study

Background: Spinal cord injury (SCI) is a chronic condition leading to physical and psychological problems along with numerous economic burdens for patients. In late 2019, an unknown disease called COVID-19 broke out, which quickly spread throughout the world. Objectives: The aim of the present study was to determine the challenges of SCI patients during the COVID-19 pandemic. Methods: This was a qualitative study performed among SCI patients after obtaining the code of ethics from the Research Ethics Committee of Ilam University of Medical Sciences in 2021. Data were collected using semi-structured, face-to-face individual interviews, in accordance with health protocols, in a safe environment without stress until reaching data saturation. Data were saturated after interviewing nine patients; to ensure data saturation, two additional interviews were conducted. Each interview lasted between 30 and 45 minutes, depending on the condition of each patient. The written files of the interviews were analyzed using MAXQDA software. Results: The mean age of the participants was 54 years, and 68% of the participants were male. After analyzing the data obtained from in-person interviews, three main themes, including expectations (need for financial support, need for social support, and need for physical support), concerns (fear of loneliness and fear of death), and health needs (health literacy, access to services and how to transmit the disease), were extracted. Conclusions: Considering the challenges in the three areas of expectations, concerns, and health care, it is necessary to take some measures to reduce these challenges.

Shifting loads as a result of chair articulations and associated perfusion responses in the context of pressure injuries: An investigation with able-bodied individuals

Wheelchair users with spinal cord injuries experience pressure injuries at high rates, causing a decrease in quality of life and an increased financial burden. The soft tissue in the buttocks (beneath the ischial tuberosities) and lower back (behind the sacrum) experience large interface pressures over long periods while seated, putting them at high risk of pressure injury development. The goals of this research were to evaluate the ability of an articulating chair design to redistribute pressures on the body and to affect blood perfusion in the buttocks tissue over the ischial tuberosities. Using a unique, custom-designed chair developed for this research, pressure and blood perfusion were obtained for numerous seated positions that included recline, seat pan tilt, and back articulations. Reclining the chair back increased maximum pressures in the buttocks and lower back regions, while it decreased maximum pressures in the upper back and thigh regions. Increasing seat pan tilt, or rotating the anterior edge of the seat pan above the posterior edge, decreased maximum pressures in the buttocks and lower back regions and increased perfusion in the buttocks. Results suggested that using back recline and seat pan tilt together to create a whole-body tilt increased pressures in the back and decreased pressures in the buttocks. Changes in back articulation redistributed pressure in all back regions. Thus, the articulating chair design redistributed pressures in all areas of the body and promoted blood perfusion in the buttocks while seated. Pressure redistribution and perfusion promotion are fundamental to reducing pressure injury risk.

Successful management of rhabdomyolysis with acute infection resulting from chronic sacrococcygeal pressure ulcers in a paraplegic patient: a case report

Rhabdomyolysis, a potentially life-threatening syndrome, is caused by the breakdown of skeletal muscle cells and leakage of intramyocellular contents into the bloodstream. The treatment of rhabdomyolysis resulting from chronic sacrococcygeal pressure ulcers has been rarely reported. A 62-year-old man developed a high fever and dark-colored urine. For the past 30 years, he had lived with paraplegia, which led to his immobility. Physical examination showed evidence of repeated dehiscence and exudation of the wound on his sacrococcygeal region with loss of skin sensation. Upon corroboration of the physical examination findings and laboratory test results, the patient was diagnosed with rhabdomyolysis with an acute infection resulting from sacrococcygeal pressure ulcers. We first debrided the necrotic tissue and then repaired the chronic ulcer. The wound dressing was changed frequently, and antimicrobial therapy and nutritional support were included in the treatment. The fever and dark-colored urine gradually resolved postoperatively. The patient’s renal function also improved according to the typical laboratory indicators, and the size of the pressure ulcers decreased to some extent. The patient was discharged after 1 month of hospitalization. This case highlights that accurate diagnosis is critical for administration of precise treatment to paraplegic patients with progressive rhabdomyolysis.

Key Components Related to Pressure Injury Formation: An Initial Investigation Into Pressure Distribution and Blood Perfusion Responses in Wheelchair Users

Soft tissue around bony prominences in the buttocks and back are high-risk areas prone to the development of pressure injuries. From a clinical perspective, prevention of pressure injuries all together is the ideal situation. Unfortunately, prevalence rates still reach 47% with recurrence rates even higher. The goals of this study were to evaluate the effects of a series of wheelchair movements, some that currently exist in commercial wheelchairs and some new, on interface pressures and perfusion under the buttocks. Twenty-seven chair positions were obtained by varying back recline, seat pan tilt, and articulation of two supports along the back. Although back recline is commonly taught by therapists to be used as a pressure relieving posture, results indicated an increase in pressures under the ischial tuberosities and sacral areas in reclined positions. Articulation of the back supports produced changes in posture moving from an "erect" to "slouched" position. These movements successfully shifted pressures across back regions. Seat pan tilt was effective in shifting pressures off the ischial tuberosity regions. Additionally, in a portion of the participants, seat pan tilt consistently increased perfusion under the ischial tuberosity region. The findings of this research suggest that movements other than back recline should be considered to more effectively alter interface pressures, particularly in high-risk regions like the sacrum and ischial tuberosities.

The impact of body mass index on one-year mortality after spinal cord injury

Objective: Evaluate the association between body mass index (BMI, kg/m²) and one-year mortality among people who survived the first 90 days after spinal cord injury (SCI).Design: Cohort study.Setting: Eighteen SCI Model Systems centers throughout the United States.Participants: 6640 participants (men, 79.6%; mean age, 42.8 ± 17.7y; Whites, 62.3%) who had an SCI between October 2006 and March 2017.Interventions: Not applicable.Outcome Measures: All-cause mortality and causes of death. Life table method was used to estimate mortality rates, while Cox proportional hazard model was conducted to assess the impact of BMI on mortality after adjusting for demographic and injury-related factors.Results: Based on BMI obtained during initial rehabilitation, participants were classified into underweight (4.2%), normal weight (41.2%), overweight (30.9%) and obese (23.8%) groups, and their corresponding one-year mortality rates were 2.6%, 1.8%, 3.1%, 3.5%, respectively (P = 0.002). After adjusting for potential confounding factors, people with obesity had a higher mortality risk than those with normal weight (hazard ratio, 1.51; 95% confidence interval, 1.00-2.28). The most frequent causes of death for people with obesity were infective and parasitic diseases and respiratory diseases, while respiratory diseases were the most frequent for people with other BMI statuses.Conclusion: People with obesity who incur an SCI need special attention to prevent early mortality. Future studies should explore factors that contribute to such a higher mortality after SCI, such as preexisting conditions and comorbidities. The effects of BMI on long-term mortality also deserve further investigation.

The content and effectiveness of self-management support interventions for people at risk of pressure ulcers: A systematic review

BACKGROUND

Pressure ulcers are a common complication with a high impact on well-being and quality of life in people with impaired mobility and/or dysfunctional pain sensations. Prevention is therefore crucial. However, persons at risk seem to experience difficulties in adhering to self-management regimens that can help to prevent or diminish the development of pressure ulcers. Self-management support interventions might help to improve their self-management skills.

OBJECTIVES

To review the content, components and effectiveness of self-management support interventions on clinical and behavioral outcomes for people at risk of pressure ulcers.

METHODS

A systematic literature search for the period of January 2000 to February 2020 was conducted in five databases (CINAHL, Cochrane, PsycINFO, PubMed, and Web of Science). Inclusion criteria were: (1) studies including persons at a high risk of pressure ulcers; (2) studies investigating interventions focused on self-management support; (3) studies describing clinical and behavioral outcomes related to prevention and care of pressure ulcers. All studies were independently screened on title, abstracts and full text by two researchers. The PRISMS taxonomy of 14 components was used to code intervention content.

RESULTS

The search yielded 5297 papers, which resulted in the inclusion of 16 papers on self-management support interventions for persons at risk of pressure ulcers. Interventions focused mostly on 'Information about condition and/or management' (13 interventions), 'Training in practical self-management activities' (7 interventions), and 'Training in psychological strategies' (6 interventions). 'Provision of equipment' was not investigated. The intensity of the interventions varied in delivery mode, frequency and duration. Improvements were found in clinical outcomes in four studies and in behavioral outcomes in ten studies. Four studies showed improvements in clinical outcomes and ten studies in behavioral outcomes. Knowledge was positively influenced in eight studies.

CONCLUSION

Self-management support interventions show potential. The extensiveness and intensity of the interventions seem to be predictive for the effectiveness, but specific content components cannot be recommended. This review revealed recommendations for future research and international consensus should be reached about patient-relevant outcomes.

Knockdown of long non-coding RNA NEAT1 relieves the inflammatory response of spinal cord injury through targeting miR-211-5p/MAPK1 axis

Spinal cord injury (SCI) is a refractory disease often accompanied by inflammation. Long non-coding RNA NEAT1 (lncRNA NEAT1) was reported to be involved in the expression of the inflammasomes, while the regulatory effect of NEAT1 on SCI was poorly investigated. Herein, we carried out further studies on the pathogenesis of SCI. PC-12 cells were incubated with lipopolysaccharide (LPS) to induce inflammation. Western blotting assay was used to measure the protein expression levels. RNA expression levels were analyzed using RT-qPCR. Cell counting kit 8 and flow cytometry assays were used to separately determine the cell viability and apoptosis rate. The targeted relationships were verified by luciferase reporter and RNA pull-down assays. It was found that LPS induced inflammation in the PC-12 cells, leading to significantly higher cell apoptosis rate and lower viability, and the expression level of NEAT1 was elevated by LPS. However, knockdown of NEAT1 partially reversed the effects of LPS. Subsequently, the potential interaction between NEAT1 and miR-211-5p was validated and miR-211-5p inhibitor was further confirmed to antagonize the effects of NEAT knockdown. The downstream target gene of miR-211-5p was predicted and verified to be MAPK1. In addition, overexpression of MAPK1 was proved to antagonize the effects of NEAT1 knockdown. Taken together, the knockdown of NEAT1 remarkably alleviated the inflammation of SCI via miR-211-5p/MAPK1 axis.

Tissue matters: In-vivo tissue properties of persons with spinal cord injuries to inform clinical models for pressure ulcer prevention

The prevalence of pressure ulcers in patients with spinal cord injuries has been estimated to be between 30% and 47%. Individuals with spinal cord injuries sit for a majority of the time, increasing the risk of developing pressure ulcers in the buttocks and thighs due to large internal stresses. Human body models have been developed to study the formation of pressure ulcers, yet a persistent limitation in these models has been the material properties used to represent the soft tissues in the buttocks and thighs. Specifically, soft tissue material property data have not included wheelchair users, such as those with spinal cord injuries. The goals of this research were 1) to determine the in-vivo material properties of soft tissue in the thighs and buttocks of individuals with spinal cord injuries and 2) compare these to properties obtained from able-bodied people. Results indicated that the proximal and middle thigh regions of those who had a spinal cord injury were softer than the same regions as able-bodied individuals, while the distal thigh regions were stiffer. These findings are vital because they indicate that models developed using properties from able-bodied individuals will not produce internal stress or strain magnitudes that represent individuals who have a spinal cord injury. This information suggests that models should obtain material property data sets from their desired population. Human body models must represent the population being studied if they are to inform clinical assessments and make accurate patient predictions.

A Systematic review and meta-analysis of sensate versus non-sensate flaps for the prevention of pressure ulcer recurrence among individuals with spinal cord disease

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome.

METHODS

PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible.

RESULTS

Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE.

CONCLUSION

Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

Multiple Flaps for Trochanteric Pressure Sore Reconstruction: A Case Series

Trochanteric pressure sores can be quite difficult to treat, especially in cases of large bone involvement requiring a wide debridement. The residual wound is large and deep, and the reconstruction must ensure a complete fill of all dead spaces, then must be covered with adequate tissue to allow for healing, and reduce the risk of recurrence.

We report a case series of spinal cord-injured patients affected by a trochanteric pressure sore. The reconstruction was achieved using a combination of muscle and a cutaneous muscle flap from the thigh. The result was complete healing of the wound with no recurrence at 18 months.

In these cases, muscle or musculocutaneous flaps are the better choices because they permit the use of a good volume of viable tissue. In some cases, the flap can be combined to obtain a better result.

What is the frequency of pressure injury in vascular patients undergoing major amputations?

Individuals with peripheral arterial disease who have undergone below or above knee amputations have limited mobility and may sit for long periods of time in a wheelchair, increasing their risk for pressure injury. The aim of this descriptive cross-sectional research study was to retrospectively review the charts of those patients with peripheral arterial disease undergoing lower limb amputations from 2016 to 2017 at a major academic medical center to determine the frequency of pressure injury. Hospital data were used to identify patients discharged from 2016 to 2017 with primary International Classification of Diseases (10th Revision) codes for below knee amputations/above knee amputations and pressure injury (ulcer). From 2016 to 2017, 46 patients were admitted to the inpatient vascular surgery service for a below or above knee amputation. Seventeen of those patients had documented pressure injuries at hospital discharge for a frequency of 37%. There were 11 males and 6 females with age range of 44 to 82 years with a mean age of 66 years. There was a total of 19 pressure injuries (2 patients had 2 pressure injuries). Ten of those 19 pressure injuries were present on admission to the hospital and 9 pressure injuries were hospital-acquired pressure injuries. Thirteen of the 19 pressure injuries (68%) were on the sacrum. Three of the pressure injuries (16%) were on the heel. Two (11%) were ischial pressure injuries with one knee (5%) pressure injury. Risk assessment is an essential part of vascular nursing practice that aims to identify individuals at risk for pressure injury with appropriate interventions to prevent their occurrence. Vascular nurses should be encouraged to educate patients/family members on the increased risk of pressure injuries in those undergoing amputation during hospitalization and after discharge to prevent them from occurring.

The effect of educational intervention on the knowledge and attitude of intensive care nurses in the prevention of pressure ulcers

BACKGROUND

Pressure ulcers can cause disability, which can lead to a default in patients' safety and results in frequent complications for patients.

OBJECTIVES

This study aimed to determine the effect of educational intervention on nurses' knowledge and attitude in preventing pressure ulcers.

METHODS

In this study, 67 nurses of ICU wards at Ilam University of Medical Sciences were randomly assigned to the experimental or control group. Data collection tools included the demographic characteristics questionnaire, the Pieper Pressure Ulcer Knowledge test (PUKT) and the Attitude toward Pressure Ulcer tool (APuP). In the experimental group, the nurses were allocated into groups of four-five persons and for each group four face-to-face training sessions and two virtual training sessions by means of educational videos on bed sores were performed. Gathered data were analyzed using SPSS software version 16, and descriptive and analytical tests were performed.

RESULTS

PUKT questionnaire score in the experimental group improved from 15.68 (3.42) to 29.75 (12.33) (P = 0.000), while in the control group it was 16.40 (3.13) and 17.54 (6.62) before intervention, which was not significant (P > 0.05). Furthermore, the APUP questionnaire score in the experimental group improved from 27.12 (2.13) to 39.37 (3.21) (P = 0.000), while in the control group it was 27.65 (1.71) and 28.37 (5.00) before intervention, which was not significant (P > 0.05).

CONCLUSIONS

Since educational intervention improved the knowledge and attitude of nurses in preventing pressure ulcers, it is required to conduct appropriate educational interventions to improve their knowledge and attitude.

Electrical stimulation for treating pressure ulcers

BACKGROUND

Pressure ulcers (also known as pressure sores, decubitus ulcers or bedsores) are localised injuries to the skin or underlying tissue, or both. Pressure ulcers are a disabling consequence of immobility. Electrical stimulation (ES) is widely used for the treatment of pressure ulcers. However, it is not clear whether ES is effective.

OBJECTIVES

To determine the effects (benefits and harms) of electrical stimulation (ES) for treating pressure ulcers.

SEARCH METHODS

In July 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. We did not impose any restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs) comparing ES (plus standard care) with sham/no ES (plus standard care) for treating pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 20 studies with 913 participants. The mean age of participants ranged from 26 to 83 years; 50% were male. ES was administered for a median (interquartile range (IQR)) duration of five (4 to 8) hours per week. The chronicity of the pressure ulcers was variable, ranging from a mean of four days to more than 12 months. Most of the pressure ulcers were on the sacral and coccygeal region (30%), and most were stage III (45%). Half the studies were at risk of performance and detection bias, and 25% were at risk of attrition and selective reporting bias. Overall, the GRADE assessment of the certainty of evidence for outcomes was moderate to very low. Nineteen studies were conducted in four different settings, including rehabilitation and geriatric hospitals, medical centres, a residential care centre, and a community-based centre. ES probably increases the proportion of pressure ulcers healed compared with no ES (risk ratio (RR) 1.99, 95% confidence interval (CI) 1.39 to 2.85; I² = 0%; 11 studies, 501 participants (512 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. It is uncertain whether ES decreases pressure ulcer severity on a composite measure compared with no ES (mean difference (MD) -2.43, 95% CI -6.14 to 1.28; 1 study, 15 participants (15 pressure ulcers) and whether ES decreases the surface area of pressure ulcers when compared with no ES (12 studies; 494 participants (505 pressure ulcers)). Data for the surface area of pressure ulcers were not pooled because there was considerable statistical heterogeneity between studies (I² = 96%) but the point estimates for the MD of each study ranged from -0.90 cm² to 10.37 cm². We downgraded the evidence to very low certainty due to risk of bias, inconsistency and imprecision. It is uncertain whether ES decreases the time to complete healing of pressure ulcers compared with no ES (hazard ratio (HR) 1.06, 95% CI 0.47 to 2.41; I² = 0%; 2 studies, 55 participants (55 pressure ulcers)). We downgraded the evidence to very low certainty due to risk of bias, indirectness and imprecision. ES may be associated with an excess of, or difference in, adverse events (13 studies; 586 participants (602 pressure ulcers)). Data for adverse events were not pooled but the types of reported adverse events included skin redness, itchy skin, dizziness and delusions, deterioration of the pressure ulcer, limb amputation, and occasionally death. We downgraded the evidence to low certainty due to risk of selection and attrition bias and imprecision. ES probably increases the rate of pressure ulcer healing compared with no ES (MD 4.59% per week, 95% CI 3.49 to 5.69; I² = 25%; 12 studies, 561 participants (613 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. We did not find any studies that looked at quality of life, depression, or consumers' perception of treatment effectiveness.

AUTHORS' CONCLUSIONS

ES probably increases the proportion of pressure ulcers healed and the rate of pressure ulcer healing (moderate certainty evidence), but its effect on time to complete healing is uncertain compared with no ES (very low certainty evidence). It is also uncertain whether ES decreases the surface area of pressure ulcers. The evidence to date is insufficient to support the widespread use of ES for pressure ulcers outside of research. Future research needs to focus on large-scale trials to determine the effect of ES on all key outcomes.

Effectiveness of high frequency ultrasound on pressure ulcer: A systematic review protocol of randomized controlled trial

BACKGROUND

This study aims to systematically assess the effectiveness of high frequency ultrasound (HFUS) on pressure ulcer (PU).

METHODS

In this study, PubMed, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be searched from inception to the present without any language limitations. The primary outcomes include change in ulcer area, and time complete healing. The secondary outcomes consist of proportion of ulcers healed within trial period, quality of life, pain intensity, and adverse events. Cochrane risk of bias tool will be used to assess methodological quality. RevMan 5.3 software (London, UK) will be used to analyze the data.

RESULTS

This study will analyze change in ulcer area, time complete healing, proportion of ulcers healed within study period, quality of life, pain intensity, and adverse events on HFUS in patients with PU.

CONCLUSION

This study will provide most recent evidence for the effectiveness and safety of HFUS for patients with PU.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019138177.