Prevention of Hospital-acquired Pressure Ulcers in the Operating Room and Beyond: A Successful Monitoring and Intervention Strategy Program

Risk constellation of hospital acquired pressure injuries in patients with a spinal cord injury/ disorder - focus on time since spinal cord injury/ disorder and patients' age

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The aim of this study was to evaluate how time since spinal cord injury/disorder (SCI/D) and patients' age influence risk constellation for hospital acquired pressure injuries (HAPI) in patients with a SCI/D.

SETTING

Acute care and rehabilitation clinic specialized in SCI/D.

METHODS

We collected patients' characteristics and 85 risk factors for HAPI development in adults with SCI/D with at least one HAPI during their inpatient stay between August 2018 and December 2019. We analyzed patients' characteristics and HAPI risk factors using descriptive statistics according to time since SCI/D ( < 1 year, 1-15 years, > 15 years) and patients' age (18-35 years, 35-65 years, > 65 years).

RESULTS

We identified 182 HAPI in 96 patients. Comparing patients with SCI/D < 1 year with the other groups, autonomic dysreflexia (p < 0.001), abnormal body temperature (p = 0.001), hypertensive episode (p = 0.005), and pneumonia (p < 0.001) occurred more frequently; mean hemoglobin (p < 0.001), albumin (p = 0.002) and vitamin D levels (p = 0.013) were significantly lower, and patients with time since SCI/D < 1 year scored fewer points (10-12) on the Braden Scale (p < 0.001). Comparing groups per patients' age, only the SCIPUS score was higher in patients > 65 years compared to the other two groups (p = 0.002).

CONCLUSIONS

Different risk factor constellation seem to be underlying HAPI development with more differences in patients time since SCI/D than patients' age. Awareness of these differences in risk factor constellation depending on time since SCI/D in these patients might lead to different HAPI prevention strategies.

SPONSORSHIP

The study team didn't receive any additional sponsorship.

Defining Practices to Avoid Hospital-Acquired Pressure Injuries in the Operating Room

BACKGROUND

Data from the Agency for Healthcare Research and Quality indicate that hospital-acquired pressure injuries (HAPIs) and surgical site infections are the only 2 hospital-acquired conditions that have not improved. Consequently, health systems around the nation are struggling to lower HAPI rates and avoid penalties. All patient care areas of the hospital play a part in pressure injury (PI) development. Analysis of real-time PI data and completion of root cause analysis related to HAPIs can guide organizational leaders to specific clinical areas in need of improvement. Surgical patients are high risk for development of a PI due to their unique vulnerability from multiple transfers and induced immobility. Operating room (OR) nursing organizations and wound care professional organizations have published evidence-based clinical practice guidelines addressing prevention of PIs in the OR.

CASES

This article discusses 2 surgical patients from 2 different academic medical centers who experienced OR-associated HAPIs. Operating room HAPI prevention measures should include current evidence-based practice recommendations. Each hospital should take a critical look at their OR HAPI prevention procedures and measure them against the current published guidelines, changing and updating them to reflect best practices for avoiding PI development. Clinicians from both the OR and WOC nurse team can provide expertise to develop confluent nursing practice standards for OR-associated HAPI reduction.

CONCLUSION

This article highlights the commonalities found in the guidelines and encourages collaboration between WOC nurses and OR nurses in building and implementing pressure injury prevention practices associated with the OR.

Supervised machine learning-based prediction for in-hospital pressure injury development using electronic health records: A retrospective observational cohort study in a university hospital in Japan

BACKGROUND

In hospitals, nurses are responsible for pressure injury risk assessment using several kinds of risk assessment scales. However, their predictive validity is insufficient to initiate targeted preventive strategy for each patient. The use of electronic health records with machine learning technique is a promising strategy to provide automated clinical decision-making aid.

OBJECTIVE

The purpose of this study was to construct a predictive model for pressure injury development which included feature variables that can be collected on the first day of hospitalization by nurses who routinely input the data to electronic health records.

DESIGN

Retrospective observational cohort study.

SETTING

This study was conducted at a university hospital in Japan.

PARTICIPANTS

This study used electronic health records, which include entry/discharge records, basic nursing records, and pressure injury management documents (N = 75,353).

METHODS

The outcome measure was the pressure injuries which developed outside of an operation theatre and frequently appeared on the specific body parts at high risk of pressure injury development. We utilized four major classifiers: logistic regression, random forest, linear support vector machine, and extreme gradient boosting (XGBoost) with 5-fold cross-validation technique. The area under the receiver operating characteristic curve (AUC) was used for evaluating predictive performance.

RESULTS

The proportion of hospital-acquired pressure injuries was 0.52%. The receiver operating characteristic curves revealed the best predictive performance for the XGBoost model, achieving the highest sensitivity of 0.78±0.03 and AUC of 0.80±0.02 amongst four types of classifiers. Variables related to difficulty in activities of daily living, anorexia, and respiratory or cardiac disorders were extracted as important features.

CONCLUSIONS

Our findings suggest that routinely collected health data by nurses on the first day of patient admission have the potential to help determine high-risk patients for pressure injury development. Tweetable abstract: Machine learning models on routinely collected electronic health records data successfully predict pressure injury development during hospitalization.

FUNDING

This work was supported by a JSPS KAKENHI Grant-in-Aid for Exploratory Research (16K15865).

A comparison of air-cell and gel surgical table pads and an evaluation of the influence of pressure distribution and other factors on pressure injury prevention

Guidelines for pressure injury prevention consider the use of pressure-redistributing pads to prevent tissue deformation. However, limited research exists to assess the pressure distribution provided by the operating tables and the effectiveness of pressure-redistributing pads in preventing pressure injuries. In this study, we compared the pressure distribution properties of two surgical table pads and identified parameters influencing pressure injury outcomes after a lengthy surgical procedure. Twenty-seven patients undergoing left ventricular assist device implantation surgery participated in the study. Participants were randomly assigned to use either an air cell-based pad or a gel pad. Interface pressure was recorded during the surgery. We analyzed the effect of surgical table pad type, interface pressure distribution and pressure injury outcomes and analyzed what characteristics of the patients and the interface pressure are most influential for the development of pressure injuries. Comparing the interface pressure parameters between the air-cell group and the gel group, only the peak pressure index x time was significantly different (p < 0.05). We used univariate logistic regression analysis to identify significant predictors for the pressure injury outcome. The support surface was not significant. And, among patient characteristics, only age and BMI were significant (p ≤ 0.05). Among the interface pressure parameters, pressure density maxima, peak pressure index x time, and coefficient of variation were significant for pressure injury outcome (p ≤ 0.05). Peak pressure index, average pressure, and the surgery length were not statistically significant for pressure injury outcomes.

Pressure Ulcers: Factors Contributing to Their Development in the OR

The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures.

Free Flap Procedures for Reconstruction After Head and Neck Cancer

Patients with head and neck cancer are seeking improved surgical procedures to avoid severe defects that result from head and neck cancer resection. Free flap reconstruction provides vascularized tissue that has been transferred from a distant donor site on a patient's body to a recipient site, markedly improving wound closure and protecting structures of the head and neck. This article discusses free flap procedures for reconstruction after head and neck cancer resection, including the following procedure phases: airway protection and neck dissections, tumor resection, flap harvest, microvascular anastomosis of the flap, and reconstruction and closure. The article also explains specific risk factors for patients undergoing free flap procedures that have been identified in the literature and include procedure length, hypothermia, and pressure injuries. Each of these factors is discussed regarding its specific effect on this patient population, and the nursing interventions to reduce these risks are identified.

Improving Outcomes by Implementing a Pressure Ulcer Prevention Program (PUPP): Going beyond the Basics

A multidisciplinary process improvement program was initiated at the University of Miami Hospital (UMH) in 2009 to identify the prevalence of hospital-acquired pressure ulcers (HAPU) at the institution and to implement interventions to reduce the incidence of HAPU. This deliberate and thoughtful committee-driven process evaluated care, monitored results, and designed evidence-based strategic initiatives to manage and reduce the rate of HAPU. As a result all inpatient beds were replaced with support surfaces, updated care delivery protocols were created, and monitored, turning schedules were addressed, and a wound, ostomy, and continence (WOC) nurse and support staff were hired. These initial interventions resulted in a decrease in the prevalence of HAPU at UMH from 11.7% of stage II to IV ulcers in the second quarter, 2009 to 2.1% the third quarter. The rate remained at or near the 2009 UMH benchmark of 3.1% until the first quarter of 2012 when the rate rose to 4.1%. At that time new skin products were introduced into practice and continuing re-education was provided. The rate of HAPU dropped to 2.76% by the second quarter of 2012 and has remained steadily low at 1%-2% for nine consecutive quarters.