Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study

Construction of a Risk Prediction Model for the Occurrence of Acute Skin Failure in Critically Ill Patients: A Prospective Study

BACKGROUND

The risk factors for acute skin failure (ASF), a serious complication of the skin, are not fully understood.

PURPOSE

This study was designed to explore the risk factors for ASF in critically ill patients and construct a clinical prediction model.

METHODS

Intensive care unit patients were prospectively observed and assigned into two groups: with and without ASF. A logistic regression model was constructed, and its predictive power and clinical utility were evaluated.

RESULTS

Of the 204 eligible patients enrolled as participants, 58 (28.43%) developed ASF. Sepsis, vasoactive drugs, and age were shown to be risk factors for ASF, whereas peripheral perfusion index ratio and albumin level were shown to be protective factors. The area under the receiver operating characteristic curve was 0.83. The maximum Youden index of the model was 0.39 (specificity: 0.87, sensitivity: 0.77). The Hosmer-Lemeshow test (p = .20) and calibration curve showed good fitness and predictive utility with respect to the model.

CONCLUSIONS

The developed model effectively predicts ASF risk, allowing for the early identification of high-risk patients. Identifying risk factors such as sepsis, vasoactive drugs, and age and considering protective factors such as peripheral perfusion index and albumin levels may help optimize care plans. Clinical staff should pay special attention to these factors and their impact on skin health in critically ill patients.

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

PURPOSE

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

DESIGN

This was a retrospective, descriptive, comparative research study.

SUBJECTS AND SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A survey of skin failure perceptions amongst pressure injury management staff in China: A cross-sectional study

This study sought to evaluate the perceptions of pressure injury (PI) management staff regarding skin failure (SF). Additionally, an analysis of influencing factors based on the collected data was conducted to establish a foundation for targeted SF training. A descriptive, cross-sectional survey was undertaken in October-November 2023, utilising a convenience sampling method involving selected management staff of PI from 16 provinces in China. A total of 501 nursing participants were included, exhibiting an overall perception level that was moderately low. Although the majority were aware of the possibility of SF (n = 417, 83.23%), only 60% reported an understanding of the fundamentals of SF, with the lowest level of comprehension observed in differentiating between SF and PI (n = 212, 42.31%). Overall attitudes were generally positive. Regarding behaviour, active learning was more prevalent (n = 340, 67.86%), but training is less (n = 287, 57.29%). Family education (n = 401, 80.04%) and nursing record monitoring (n = 426, 85.03%) demonstrated better behaviour. Further analysis revealed that training (t = 13.937, p < 0.001) and professional title (F = 4.681, p = 0.010) had a significant effect on participants' perceptions. These findings underscore that there remains a substantial lack of perception about SF amongst participants. Overall, participants exhibited a positive attitude towards SF, highlighting the need for future improvements in SF training.

Evaluating the Effects of a General Anesthesia and Prone Position Nursing Checklist and Training Course on Posterior Lumbar Surgery: A Randomized Controlled Trial

BACKGROUND

While general anesthesia in the prone position is one of the most utilized surgical positions, it predisposes to multiple types of complications. Existing studies on this topic are mostly literature reviews or focus on solving one complication, which limits their clinical use.

OBJECTIVE

The aims of the study were to evaluate the effectiveness of a 22-item general anesthesia and prone position nursing checklist and specific training course at preventing complications related to general anesthesia in the prone position.

DESIGN

The study used a randomized controlled trial.

SETTINGS AND PARTICIPANTS

Convenience sampling was used to recruit patients who underwent general anesthesia during posterior lumbar surgery from July 2021 to December 2021 at the Run Run Shaw Hospital, Zhejiang University School of Medicine Hospital.

METHODS

Patients involved in the study were randomly assigned to the control (standard general anesthesia and prone position care) or experimental group (general anesthesia and prone position nursing checklist combined with specific training course in addition to standard general anesthesia and prone position care). Outcomes were pressure injuries, peripheral nerve injuries, ocular complications, and length of stay (LOS). Patient satisfaction, Numeric Pain Rating Scale (NRS) and the Oswestry Disability Scale were also measured.

RESULTS

Compared with the control group, pressure injury, brachial plexus injury, and two ocular findings (foreign body sensation and blurry vision) were significantly less common in the intervention group ( P ≤ 0.01). Participants who received standard general anesthesia and prone position care had lower self-reported satisfaction than those managed with the general anesthesia and prone position nursing checklist plus specific training course ( P = 0.002). The checklist-based intervention also significantly reduced LOS ( P = 0.000) and NRS ( P = 0.000).

CONCLUSIONS

The intervention group had significant fewer general anesthesia in the prone position-related complications, improved satisfaction, reduced LOS, and lower NRS. These findings suggest that a general anesthesia and prone position nursing checklist in addition to a specific training course are beneficial to standardizing prone position nursing care during posterior lumbar surgery.

Data-driven approach to predicting the risk of pressure injury: A retrospective analysis based on changes in patient conditions

AIMS

To determine the risk of pressure injury development in the intensive care unit based on changes in patient conditions.

DESIGN

This retrospective study was based on secondary data analysis.

METHODS

Patient data from electronic health records were retrospectively obtained and we included 438 and 1752 patients with and without pressure injury, respectively, among those admitted to the medical and surgical intensive care units (ICUs) from January 2017-February 2020. Changes in patient conditions were analysed based on the first and last objective data values from the day of ICU admission to the day before the onset of pressure injury and categorised as follows: improved, maintained normal, exacerbated and unchanged. Logistic regression was performed to identify the significant predictors of pressure injury development based on 11 variables.

RESULTS

The 11 selected variables were age, body mass index, activity, acute physiology and chronic health evaluation II score, nursing severity level, pulse and albumin, haematocrit, C-reactive protein, total bilirubin and blood urea nitrogen levels. The risk for a pressure injury was high with exacerbation of or persistently abnormal levels of nursing severity, albumin, haematocrit, C-reactive protein, blood urea nitrogen and pulse >100 beat/min.

CONCLUSION

Periodic monitoring of haematological variables is important for preventing pressure injury in the intensive care unit.

REPORTING METHOD

The study followed STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

This study contributes to the utilisation of patient data from electronic health records.

RELEVANCE TO CLINICAL PRACTICE

In addition to other pressure injury risk assessment tools, ICU nurses can help prevent pressure injuries by assessing patients' blood test results, thereby promoting patient safety and enhancing the efficacy of nursing practice.

Vasoconstrictor Agent Administration as a Risk Factor for Pressure Injury Development in Intensive Care Unit Patients: A Systematic Review and Meta-Analysis

Significance: Pressure injury (PI) is a common critical presentation in intensive care units (ICU) and is an important clinical concern in critical care settings. Some developing data support the vasoconstrictor agent administration as a potential risk factor; however, synthesis of available evidence has not been completed. Recent Advances: Comprehensive tactics were employed to search electronic databases PubMed, Web of Science, and Ovid Embase for data on vasoconstrictor agent administration associated with PI in ICU patients. Extraction was limited to studies that matched the inclusion criteria. The pooled odds ratio and 95% confidence intervals (95% CI) were calculated for dichotomous outcomes. Critical Issues: Twenty-six studies were included, involving 50,192 patients who matched the selection criteria. Around 5.8% of patients (2,523/43,210) got PI in total. PI occurred in 10.9% (1,496/13,675) of the vasoconstrictor agent administration population and 3.5% (1,027/29,503) of the drug-free population. The pooled unadjusted odds ratio was 2.83 (95% CI = 2.21-3.64, p < 0.001). The adjusted odds ratio was 1.83 (95% CI = 1.26-2.68, p = 0.002). Subgroup analysis and meta-regression found that the risk of PI did not vary with research design, time of occurrence, patient age, or male proportion. Future Directions: Vasoconstrictor agent administration raised the risk of PI in critical care patients by nearly twofold. More emphasis should be placed on the timely prevention of PI in patients receiving vasoconstrictor agent administration in the ICU.

Establishment and Validation of the Risk Nomogram of Poor Prognosis in Patients with Severe Pulmonary Infection Complicated with Respiratory Failure

Objective

To investigate the prognosis of patients with severe pulmonary infection combined with respiratory failure and analyze the influencing factors of prognosis.

Methods

The clinical data of 218 patients with severe pneumonia complicated with respiratory failure were retrospectively analyzed. The risk factors were analyzed by univariate and multivariate logistic regression analyses. The risk nomogram and Bootstrap self-sampling method were used for internal inspection. Calibration curves and receiver operating characteristic (ROC) curve were drawn to assess the predictive ability of the model.

Results

Among 218 patients, 118 (54.13%) cases had a good prognosis and 100 (45.87%) cases had a poor prognosis. Multivariate logistic regression analysis showed that the number of complicated basic diseases ≥5, APACHE II score >20, MODS score >10, PSI score >90, and multi-drug resistant bacterial infection were independent risk factors affecting the prognosis (P<0.05), and the level of Alb was an independent protective factor (P<0.05). The consistency index (C-index) was 0.775, and the Hosmer Lemeshow goodness-of-fit test showed that the model was not significant (P>0.05). The area under the curve (AUC) was 0.813 (95% CI: 0.778~0.895), with the sensitivity of 83.20%, and the specificity of 77.00%.

Conclusion

The risk nomograph model had good discrimination and accuracy in predicting the prognosis of patients with severe pulmonary infection combined with respiratory failure, which may provide a basis for early identification and intervention of patients at clinical risk and improve the prognosis.

Pressure Injury Prevention and Management: A Gap Analysis Using Key Stakeholder Engagement

The purpose of this study was to examine pressure injury prevention and management (PIPM) practices in an academic acute care setting. Specific aims were to (1) develop and examine key stakeholder engagement regarding PIPM practices, (2) develop a valid/reliable gap analysis instrument, and (3) conduct a gap analysis of current PIPM practices.

APACHE scoring system and pressure injury risk for intensive care patients: A systematic review and meta-analysis

The present study was designed to determine the association between Acute Physiology and Chronic Health Evaluation (APACHE) scale and elevated pressure injure (PI) risk in intensive care units (ICU) and also evaluate the predictive value of APACHE score in PI patients. Comprehensive strategies were used to search studies from PubMed, Web of Science, and Ovid Embase electronic databases for observational studies that provided data about APACHE scores related to PI in ICU. Eligible studies were selected based on inclusion and exclusion criteria. The pooled SMD with 95% confidence intervals were calculated. A summary ROC curve was plotted to calculate area under curve (AUC) for APACHE-II (15-20). Twenty-one studies involving 11,102 patients who met selection criteria were included. The 11.0% of patients (1229/11102) in ICU developed PIs. Overall, the PI group had a higher score compared with the non-PI group in the APACHE II (22.1 ± 8.0 vs. 14.5 ± 7.4, mean ± SD). The APACHE-III of PI patients was significantly more than that in the non-PI group (79.9 ± 25.6 vs. 59.9 ± 30.4, mean ± SD). The pooled SMD was 0.82 (95% CI: 0.58-1.06, I²  = 91.7%, p-value < 0.001). The subgroup analysis revealed that the risk of PIs did not vary with the type of APACHE score (II, III, IV) and the type of study design (case-control, cross-sectional, cohort, longitudinal study). Proportion of males (I²  = 91.68%, p value = 0.090), publish year (I²  = 91.96%, p value = 0.187) and mean age of patients (I²  = 91.96%, p value = 0.937) were not the sources of heterogeneity. APACHE-II (15-20) achieves the best predictive performance in PI, and the prediction accuracy was balanced with equal sensitivity and specificity (Sen: 0.72, 0.62-0.80; Spec: 1.72, 1.25-2.38). In conclusion, higher APACHE scores are frequently accompanied by a higher incidence of PI among critical-care patients. APACHE-II scores (15-20) satisfactorily predicted PI, and strategies to prevent PI should be aggressively implemented.

A Crosswalk Analysis Between Magnet® Standards and Clinical Nurse Specialist Practice Competencies

OBJECTIVE

The purpose of this study was to determine the alignment between the American Nurses Credentialing Center's Magnet Recognition Program® standards and clinical nurse specialist (CNS) practice competencies.

BACKGROUND

Despite documentation of CNS contributions to achieving and sustaining Magnet Recognition®, there is a lack of evidence clearly aligning Magnet® standards and CNS practice competencies.

METHODS

Using a crosswalk method, an expert panel of CNSs and chief nursing executives analyzed alignment of the 50 Magnet standards with the 44 National Association of Clinical Nurse Specialists core practice competencies.

RESULTS

CNS practice competencies are aligned closely with Magnet standards: 86% of the 50 Magnet standards aligned with at least 1 CNS competency and 81.8% of CNS competencies aligned with at least 1 Magnet® standard.

CONCLUSIONS

The alignment between Magnet standards and CNS competencies supports evidence of CNS contributions to organizational achievement of Magnet Recognition and will assist nurse executives in identifying a full scope of opportunities for CNSs to contribute to nursing excellence.

Efficacy and safety of neuromuscular electrical stimulation in the prevention of pressure injuries in critically ill patients: a randomized controlled trial

Background

Pressure injuries (PIs), especially in the sacral region are frequent, costly, and increase morbidity and mortality of patients in an intensive care unit (ICU). These injuries can occur as a result of prolonged pressure and/or shear forces. Neuromuscular electrical stimulation (NMES) can increase muscle mass and improve local circulation, potentially reducing the incidence of PI.

Methods

We performed a randomized controlled trial to assess the efficacy and safety of NMES in preventing PI in critically ill patients. We included patients with a period of less than 48 h in the ICU, aged ≥ 18 years. Participants were randomly selected (1:1 ratio) to receive NMES and usual care (NMES group) or only usual care (control group—CG) until discharge, death, or onset of a PI. To assess the effectiveness of NMES, we calculated the relative risk (RR) and number needed to treat (NNT). We assessed the muscle thickness of the gluteus maximus by ultrasonography. To assess safety, we analyzed the effects of NMES on vital signs and checked for the presence of skin burns in the stimulated areas. Clinical outcomes were assessed by time on mechanical ventilation, ICU mortality rate, and length of stay in the ICU.

Results

We enrolled 149 participants, 76 in the NMES group. PIs were present in 26 (35.6%) patients in the CG and 4 (5.3%) in the NMES group (p ˂ 0.001). The NMES group had an RR = 0.15 (95% CI 0.05–0.40) to develop a PI, NNT = 3.3 (95% CI 2.3–5.9). Moreover, the NMES group presented a shorter length of stay in the ICU: Δ = − 1.8 ± 1.2 days, p = 0.04. There was no significant difference in gluteus maximus thickness between groups (CG: Δ = − 0.37 ± 1.2 cm vs. NMES group: Δ = 0 ± 0.98 cm, p = 0.33). NMES did not promote deleterious changes in vital signs and we did not detect skin burns.

Conclusions

NMES is an effective and safe therapy for the prevention of PI in critically ill patients and may reduce length of stay in the ICU.

Trial registration RBR-8nt9m4. Registered prospectively on July 20th, 2018, https://ensaiosclinicos.gov.br/rg/RBR-8nt9m4

Palliative Wound Care: Case Studies

Patients with advanced illness may present to palliative care or hospice with unmanaged symptoms that may be exacerbated by the presence of a wound. The wound can be a constant reminder to the patient and caregiver of the underlying illness. Distressing symptoms such as wound pain, odor, bleeding, and/or excessive exudate may impede the patients' ability to spend quality time with loved ones when they need them the most. Although patients may present with wounds of varying etiologies, the most common wounds seen in this patient population are pressure-related injuries. However, there is a shortage of both wound and palliative specialized clinicians. Telehealth and the use of other technology can be a way to address this shortage. This will grant access to a broader number of patients to ensure appropriate wound care plans are in place to meet the goals of care. Although wound healing may not always be possible in this patient population, having access to specialized wound and palliative experts can improve the quality of life for patients and their caregivers.

Pressure Injury Prevalence in Acute Care Hospitals With Unit-Specific Analysis: Results From the International Pressure Ulcer Prevalence (IPUP) Survey Database

PURPOSE

The purpose of this study was to determine overall pressure injury (PI) prevalence and hospital-acquired pressure injury (HAPI) prevalence in US acute care hospitals. Additionally, analysis of patient characteristics associated with HAPIs will be presented.

DESIGN

Observational, cross-sectional cohort study.

SUBJECTS AND SETTING

An in-depth analysis of data was performed from the International Pressure Ulcer Prevalence™ (IPUP) Survey database for years 2018-2019 that included 296,014 patients. There were 914 participating US acute care facilities in 2018 and 887 in 2019. Overall PI prevalence and HAPI prevalence over time were also examined for 2006-2019 acute care data from 2703 unique facilities (1,179,108 patients).

METHODS

Overall PI prevalence and HAPI prevalence were analyzed from the 2006-2019 IPUP survey database. Recent data for 2018-2019 PI prevalence are reported separately for medical-surgical, step-down, and critical care unit types. PI stages, anatomic locations, Braden score associated with HAPIs, and body mass index were analyzed.

RESULTS

Overall PI prevalence and HAPI prevalence data declined between 2006 and 2019; however, the prevalence plateaued in the years 2015-2019. Data from 2018 to 2019 (N = 296,014) showed that 26,562 patients (8.97%) had at least one PI and 7631 (2.58%) had at least one HAPI. Patients cared for in medical-surgical inpatient care units had the lowest overall PI prevalence (7.78%) and HAPI prevalence (1.87%), while critical care patients had the highest overall PI prevalence (14.32%) and HAPI prevalence (5.85%). Critical care patients developed more severe PIs (stage 3,4, unstageable, and deep-tissue pressure injuries [DTPIs]), which were proportionally higher than those in the step-down or medical-surgical units. The sacrum/coccyx anatomic location had the highest overall PI prevalence and HAPI prevalence, except for DTPIs, which most common occurred on the heel.

CONCLUSIONS

Overall and HAPI prevalence has plateaued 2015-2019. Prevalence of HAPIs, especially in critical care units, remain high. While medical advancements have improved survival rates among critically ill patients, survival may come with unintended consequences, including PI development.

Medical Device-Related Pressure Injuries

Medical device-related pressure injuries result from use of medical devices, equipment, furniture, and everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage. The resultant pressure injury generally mirrors the pattern or shape of the device. The nurse and clinician must be hypervigilant of increased risk of pressure injuries with the use of these devices. This article provides evidence-based information regarding the most common devices that cause pressure injuries in adults and describes current best evidence-based prevention strategies. Evidence-based prevention strategies are key to minimizing the harm devices can cause.