Strategies to support pressure injury best practices by the inter-professional team: A systematic review

Pressure injury education for older adults and carers living in community settings: A scoping review

Older adults are at increased risk of pressure injuries (PIs) due to age-related changes. Traditionally, PI knowledge and education have been delivered in hospitals and residential aged care facilities, however, there remains a critical gap in understanding how PI knowledge on prevention and management is shared with older adults and their carers living in the community. We aimed to describe the nature and characteristics of structured and unstructured PI education programs available to community-dwelling older adults and their carers. As coping review was undertaken. We searched five databases: CINAHL, Medline, Scopus, Cochrane Library and ProQuest from 2009 to August 2023. The review was guided by Arksey and O'Malley's six-step framework and adhered to the PRISMA-ScR guidelines. It included primary peer-reviewed papers published in English, which focus on PI education for older adults and/or their carers living in community settings. Data extraction was organised in a table, and findings presented as a narrative summary. One-hundred and thirty-six papers were screened and four included in the review. Results indicate that consideration was placed on literacy levels and cognitive status of older adults and their carers when designing PI education materials. Educational materials such as leaflets/brochures, in-person training sessions or a combination of both were used. However, duration of these interventions varied, lasting for 1-4 weeks while others were completed over 12 months. Some improvements in PI knowledge such as how to treat PI, dietary requirements and importance of mobility were noted. However, information retention and its translation into effective long-term behaviour change remained unclear. In conclusion, adopting a multifaceted educational approach increases the effectiveness of PI knowledge translation. Continuous education, support and reinforcement on PIs over time are necessary when interacting with older adults and caregivers to ensure long-term management and prevention success. Conversations on PIs should start at the primary care levels when older adults and carers are visiting their GP clinics and accessing support services for other healthcare needs. Understanding older adults' and carers' literacy levels, cognitive status and cultural background can assist clinicians in designing and delivering fit-for-purpose PI educational interventions that are accessible, relatable and effective in promoting knowledge transfer and behaviour change. Carers are vital conduits in the care continuum. These factors will lead to a more informed, collaborative and person-centred approaches to PI management and prevention.

Educational interventions on preventing pressure injuries targeted at nurses: systematic review and meta-analysis

BACKGROUND

Although preventable, pressure injuries are commonly observed in the hospital setting and are estimated to be the third most costly condition, after cancer and cardiovascular disease.

AIM

Nurses play a crucial role in the prevention and management of pressure injuries, however, published evidence on the effectiveness of educational interventions, directed specifically at nurses in the hospital environment, is scarce.

METHOD

The authors retrieved published studies on the subject from selected databases (Pubmed/Medline, Embase, Web of Science and the Cochrane Library) in a number of languages (Portuguese, English, French and Spanish). The search yielded randomised controlled trials, as well as quasi-experimental and comparative studies.

FINDINGS

In total, 11 studies were selected. The outcomes analysed, following some type of educational intervention, included the attitudes and knowledge of the nursing professionals, as well as the incidence of pressure injuries.

CONCLUSION

The present study demonstrated that different educational strategies can help prevent pressure injuries in the hospital environment.

Barriers and facilitators to implementing pressure injury prevention and management guidelines in acute care: A mixed-methods systematic review

BACKGROUND

Evidence-based pressure injury prevention and management is a global health service priority. Low uptake of pressure injury guidelines leads to compromised patient outcomes. Understanding clinicians' and patients' views on the barriers and facilitators to implementing guidelines and mapping the identified barriers and facilitators to the Theoretical Domains Framework and behaviour change techniques will inform an end-user and theoretically informed intervention to improve guideline uptake in the acute care setting.

OBJECTIVES

To synthesise quantitative and qualitative evidence on i) hospital clinicians' and inpatients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines.

DESIGN

A convergent integrated mixed-methods systematic review was conducted using the JBI approach.

DATA SOURCE

English language peer-reviewed studies published from 2009 to August 2022 were identified from MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central Library.

REVIEW METHODS

Included studies reported: i) acute care hospital clinicians' and patients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines. The Mixed Methods Appraisal Tool was used for critical appraisal. Quantitative data was transformed into qualitised data, then thematically synthesised with qualitative data, comparing clinicians' and patients' views. Barriers and facilitators associated with each main theme were mapped to the Theoretical Domains Framework and allocated to relevant behaviour change techniques.

RESULTS

Fifty-five out of 14,488 studies of variable quality (29 quantitative, 22 qualitative, 4 mixed-methods) met the inclusion criteria. Four main themes represent factors thought to influence the implementation of evidence-based guidelines: 1) nurse-led multidisciplinary care, 2) patient participation in care, 3) practicability of implementation and 4) attitudes towards pressure injury prevention and management. Most barriers identified by clinicians were related to the third theme, whilst for patients, there were multiple barriers under theme 2. Barriers were mainly mapped to the Knowledge domain and Environmental Context and Resources domain and were matched to the behaviour change techniques of "instruction on how to perform a behaviour" and "restructuring the physical environment". Most facilitators mentioned by clinicians and patients were related to themes 1 and 2, respectively, and mapped to the Environmental Context and Resources domain. All patient-related attitudes in theme 4 were facilitators.

CONCLUSIONS

These review findings highlight the most influential factors related to implementing evidence-based pressure injury care from clinicians' and patients' views and mapping these factors to the Theoretical Domains Framework and behaviour change techniques has contributed to developing a stakeholder-tailored implementation intervention in acute care settings.

PROSPERO REGISTRATION

CRD42021250885.

COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review

OBJECTIVE

To investigate the relationship between COVID-19-related variables and hospital-acquired pressure injury (HAPI) incidence.

DATA SOURCES

The authors searched four databases: Cochrane, MEDLINE, EMBASE, and CINAHL. The literature search contained key terms such as "COVID-19," "hospital-acquired pressure injuries," "pressure ulcer," "pressure injury," "decubitus ulcer," and "hospitalization."

STUDY SELECTION

The systematic search of the literature identified 489 publications that matched the inclusion criteria. Articles were included in the review if they were peer-reviewed publications that reported HAPI incidence for patients who were hospitalized and COVID-19 positive. Two reviewers performed the screen simultaneously, and 19 publications were included.

DATA EXTRACTION

Two reviewers followed a standardized extraction form that included study and patient characteristics, COVID-19 status, HAPI characteristics, prone positioning, length of hospitalization, and HAPI prevention and treatment strategies.

DATA SYNTHESIS

The authors carried out a narrative synthesis of the extracted data because the data obtained were too heterogeneous for meta-analysis. The primary outcome was HAPI incidence.

CONCLUSIONS

This review identified that HAPI incidence was high among men who were COVID-19 positive, had longer hospital stays, experienced prone positioning, and had care teams without a skin and wound care expert. Future research should use more robust methodology and focus on quantitative modeling to iteratively improve inpatient HAPI guidelines.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Pressure injury prevention practice in Australian intensive care units: A national cross-sectional survey

INTRODUCTION

Pressure injury (PI) is an ongoing problem for patients in intensive care units (ICUs). The aim of this study was to explore the nature and extent of PI prevention practices in Australian adult ICUs.

MATERIALS AND METHODS

An Australian multicentre, cross-sectional study was conducted via telephone interview using a structured survey instrument comprising six categories: workplace demographics, patient assessment, PI prevention strategies, medical devices, skin hygiene, and other health service strategies. Publicly funded adult ICUs, accredited with the College of Intensive Care Medicine, were surveyed. Data were analysed using descriptive statistics and chi-square tests for independence to explore associations according to geographical location.

RESULTS

Of the 75 eligible ICUs, 70 responded (93% response rate). PI was considered problematic in two-thirds (68%) of all ICUs. Common PI prevention strategies included risk assessment and visual skin assessment conducted within at least 6 h of admission (70% and 73%, respectively), a structured repositioning regimen (90%), use of barrier products to protect the skin (94%), sacrum or heel prophylactic multilayered silicone foam dressings (88%), regular PI chart audits (96%), and PI quality improvement projects (90%). PI prevention rounding and safety huddles were used in 37% of ICUs, and 31% undertook PI research. Although most ICUs were supported by a facility-wide skin integrity service, it was more common in metropolitan ICUs than in rural and regional ICUs (p < 0.001). Conversely, there was greater involvement of occupational therapists in PI prevention in rural or regional ICUs than in metropolitan ICUs (p = 0.026).

DISCUSSION AND CONCLUSION

This is the first study to provide a comprehensive description of PI prevention practices in Australian ICUs. Findings demonstrate that PI prevention practices, although nuanced in some areas to geographical location, are used in multiple and varied ways across ICUs.

COVID-19 and Hospital-Acquired Pressure Injuries: A Systematic Review

OBJECTIVE

To investigate the relationship between COVID-19 related variables and hospital-acquired pressure injuries (HAPI) incidence.

DATA SOURCES

The authors searched four databases: Cochrane, MEDLINE, EMBASE, and CINAHL. The literature search contained key terms such as COVID-19, hospital-acquired pressure injuries, pressure ulcer, pressure injury, decubitus ulcer, and hospitalization.

STUDY SELECTION

The systematic search of the literature identified 489 publications that matched the inclusion criteria. This included peer-reviewed publications that reported HAPI incidence for patients who were hospitalized and COVID-19 positive. Two reviewers performed the screen simultaneously and 19 publications were included.

DATA EXTRACTION

Two reviewers followed a standardized extraction form that included study and patient characteristics, COVID-19 status, HAPI characteristics, prone positioning, length of hospitalization, and HAPI prevention and treatment strategies.

DATA SYNTHESIS

A narrative synthesis of the extracted data was carried out because the data obtained were too heterogeneous for meta-analysis. The primary outcome was HAPI incidence.

CONCLUSIONS

This review identified that HAPI incidence was high among men who were COVID-19 positive, had longer hospital stays, experienced prone positioning, and had care teams without a skin and wound care expert. Future research should employ more robust methodology and focus on quantitative modeling to iteratively improve in-patient HAPI guidelines.

Pressure ulcers in hospital patients: incidence and risk factors

OBJECTIVE

With an ageing population and a rising number of people with chronic conditions and disabilities, pressure ulcers (PUs) are a frequent problem. Prevention and treatment, especially targeted at older people, frail and non-self-sufficient patients, are central to care provided by nurses. The objective of this study is to establish the incidence of PUs in hospital inpatients and identify possible associated risk factors.

METHOD

A clinical observational study was conducted from May to November 2019 in a sample of patients admitted to Azienda Sociosanitaria Ligure 2 in Italy. Clinical and sociodemographic data were collected at admission and at discharge, through a questionnaire or collection card. The analysis was done using SAS 9.4 2017 software.

RESULTS

In 7% of the 515 participating patients, PUs occurred during hospitalisation; PUs at stages I and II were predominantly in the coccyx, heels and malleolus.

CONCLUSION

Significant associations were found between the development of lesions and age, certain pathologies, the degree of patient autonomy and the level of skin integrity.

A Patient Navigation Model to Improve Complex Wound Care Outcomes

OBJECTIVE

To create a blended format model to navigate interprofessional team assessments of patients with complex wounds during COVID-19 as a quality improvement process.

METHODS

During clinical assessments, patients were interviewed in their homes with representation from their circle of care and primary nurse on site linked to a live virtual interprofessional blended remote team model (wound care nurse specialist, advanced wound care doctor). Eligible patients had completed a wound care clinical pathway without wound closure. Palliative patients with complex wounds and patients without precise/accurate diagnoses were also included. This process addressed the components of Wound Bed Preparation 2021: manage the cause, address patient-centered concerns, determine the ability to heal, optimize local wound care, and evaluate outcomes on an ongoing basis.

RESULTS

Since April 2020, 48 patients were referred to the Home and Community Care Support Services patient navigation interprofessional team. Patients' home-care services were initiated between 2012 and 2021. The team provided closure in 29% of patients and the wound surface area reduced in 66%. Pain was reduced in 73% of patients and appropriate infection management was implemented in 79%. In addition, nursing visits were reduced by 73% and there was a 77% decrease in supply usage.

CONCLUSIONS

This project validated the Wound Bed Preparation Paradigm 2021 as a process for assessing patients with complex wounds using a blended virtual and home-based assessment. Patient navigation with this blended model benefited patients and improved healthcare system utilization with projected cost savings.

Patient and carer experience of living with a pressure injury: A meta-synthesis of qualitative studies

INTRODUCTION

Pressure injuries are a significant cause of harm, contributing to increased mortality and financial burden on the healthcare system. Significant research on pressure injury risk assessment, prevention and treatment exists, but limited research exploring the patient and carer experience of living with pressure injury.

AIMS

The aim of this meta-synthesis was to describe the patient and carer experience of living with a pressure injury.

DESIGN

Meta-synthesis.

METHODS

A prospective review protocol was registered, and systematic search conducted across five electronic databases. The PRISMA 2020 checklist for reporting systematic reviews was used. Two reviewers independently undertook screening and review of articles, using the CASP checklist for evaluating qualitative research. A meta-synthesis using thematic content analysis was undertaken.

RESULTS

Twelve studies met the inclusion criteria. Meta-synthesis led to the construction of three primary themes: loss of autonomy and independence, psychological effects, and adjustment. Within these primary themes, sub-themes of dependence, social isolation and social avoidance behaviours, feelings and emotions, loss, managing, physical consequences, service provision, and functional challenges, were identified.

CONCLUSION

The psychology and mindset of those involved, and support to navigate the challenges that arise are two unique and clinically relevant categorisations to guide provision of pressure injury care. Adaptation to a pressure injury is multi-faceted and contextual, challenges to adaptation create additional psychological burden. Interventions encompassing all facets of the experience are necessary. Current research into experiences is limited, and further research to support interventions is necessary.

Australian First-Year Nursing Student Knowledge and Attitudes on Pressure Injury Prevention: A Three-Year Educational Intervention Survey Study

Pressure injury prevention is a significant issue as pressure injuries are difficult to heal, painful, and create clinical complications for patients. The aim of this study was to investigate knowledge and attitudes of first-year nursing students to pressure injury prevention, and to explore whether additional educational interventions augmented learning. A previously validated online survey was administered to three cohorts of first-year nursing students in 2016, 2017 (after additional online education), and 2018 (after further simulation education), and a subsequent comparative analysis was undertaken. Overall, the knowledge of students about pressure injury was low with measures to prevent pressure injury or shear achieving the lowest score (<50%). Students aged over 25 years (p < 0.001) and men (p = 0.14) gained higher attitude scores. There were significant differences for mean knowledge scores between the 2016 and 2018 cohorts (p = 0.04), including age group (p = 0.013) and number of clinical training units undertaken (p = 0.23). The 2016 cohort scored consistently lower in the attitude survey than both other cohorts (p < 0.001). Online resources and simulation experiences marginally improved knowledge and improved attitudes towards prevention of pressure injury. Nursing curricula should include targeted education to ensure student nurses are adequately prepared to prevent pressure injury through understanding of aetiology and risk assessment.

A Cartoon Version of Braden Scale to Assess the Risk of Pressure Injury: Content Validity and Interrater Reliability Study

INTRODUCTION

The Braden Scale is widely used to assess the risk of pressure injury. However, the vague literal description of the items creates difficulties for bedside nurses and limits its sensitivity. To solve this problem, we developed a cartoon version of the Braden scale (CVBS) to improve the pressure injury risk assessment ability of bedside nurses.

METHODS

The CVBS was constructed by two nurses, and the final version was determined through a two-round Delphi consultation. The scale's content validity was calculated based on expert ratings. A total of 265 patients were evaluated simultaneously with the CVBS by 119 bedside nurses and 46 wound care specialists; and 114 bedside nurses and the same 46 wound care specialists evaluated 239 patients with the original Braden scale (OBS). The interrater reliability between the two groups was calculated as Kappa value, and then the Kappa values of the two versions were compared.

RESULTS

The content validity for the draft scale was not good enough. After modification, the indices of all the items in the final CVBS reached 1.00. The Kappa value of the OBS was 0.69 (95% CI 0.61-0.76); for each item, it ranged from 0.60 to 0.80. The interrater reliabilities of the CVBS were higher than those of the OBS, with an overall kappa value of 0.87 (95% CI 0.81-0.92) and a range of 0.77 to 0.93 for each item. The differences between the Kappa values of the CVBS and those of the OBS were all statistically significant.

CONCLUSIONS

The CVBS had good validity and showed higher interrater reliability than the OBS, indicating that it may improve bedside nurses' ability to assess pressure injury risk.

Hospitalists' Needs Assessment and Perceived Barriers in Wound Care Management: A Quality Improvement Project

The purpose of this quality improvement project was to determine hospitalists' knowledge, practices, and perspectives related to management of pressure injuries and neuropathic/diabetic foot complications (having a foot ulcer or subsequent development of a foot infection because of a foot ulcer). We also sought to identify resources for and knowledge-based barriers to management of these wounds. This quality improvement effort targeted an interdisciplinary group of 55 hospitalists in internal medicine that consisted of 8 nurse practitioners, 10 physician assistants, and 38 physicians. The site of this initiative was the Johns Hopkins Bayview Medical Center, a 342-bed academic hospital located in the mid-Atlantic United States (Baltimore Maryland). The first phase of our quality improvement project comprised an online survey to identify hospitalists' knowledge, practices, and opinions on inpatient management of pressure injuries and diabetic foot complications. The second phase involved semistructured focus groups attended by hospitalists to identify resource gaps and barriers inferred by survey results. Twenty-nine of 55 (52%) hospitalists responded to the survey; 72% indicated no formal training in wound care. Over 90% had little to no confidence in management of pressure injuries and diabetic foot complications. In a separate ranking section of the survey, respondents selected lack of knowledge/confidence 12 of 29 (41.3%) and resources 9 of 29 (31.0%) as number 1 barriers to wound care. Managing patients with obesity was identified as a second major barrier from 10 of 29 selected options (34.5%). Eighteen of 55 (33%) hospitalists attended focus group sessions acknowledging barriers to wound care that included provider education, information technology, system factors, and interprofessional engagement. Attendees welcomed additional educational and ancillary resource support.

Professionals' Knowledge, Attitudes, and Practices Related to Pressure Injuries in Canada

BACKGROUND

Pressure injuries (PIs) represent a significant burden on the healthcare system and have a negative impact on the quality of life of those affected by these wounds. Despite best practice guidelines and other protocols to help healthcare facilities prevent PIs, the prevalence of PIs in Canada across all healthcare settings is concerning.

OBJECTIVE

To describe the pattern of PI prevention and identify national priorities and opportunities to address PIs.

METHODS

A descriptive, cross-sectional, online survey was created between August and December 2017 to explore Canadian healthcare professionals' knowledge, attitudes, and practices related to PIs.

RESULTS

In total, 590 surveys were completed. Eighty-five percent of respondents confirmed that PIs occur in their work environments, and 29% claimed PIs are a frequent occurrence. Most of the respondents (91%) confirmed that they were part of a team that treats PIs. Of the 590 participants, 90% confirmed that they are aware of PI prevention devices and technologies. Between 80% and 90% attest to using offloading devices including prophylactic dressings to prevent PIs, but only 20% instituted measures to address moisture-associated skin damage.

CONCLUSIONS

The findings from this survey have highlighted a disconnect between Canadian healthcare professionals' awareness of PIs and the implementation of best practices for PI prevention. It is evident that, although the majority of respondents were aware of PIs and related treatment protocols, barriers still exist that impede optimized care and treatment.

Strategies to support pressure injury best practices by the inter-professional team: A systematic review

Optimal pressure injury (ulcer) management by the inter-professional team requires appropriate health care system and organisational resources, infrastructure, and policies. A systematic review was conducted on pressure injury care-related education and health care system-/organisation-level strategies. A search for relevant articles published between January 2006 and October 2014 was applied to 8 databases. Ultimately, 22 articles pertaining to education and training and 12 articles pertaining to health care system and organisation supports for pressure injury care were included in the systematic review. A lack of pressure injury assessment and management knowledge by health care professionals was an overriding theme in the education literature. Some of the methods preferred for pressure injury education among nurses and physicians included information technology (eg, e-learning) with technology support and the use of high-quality wound pictures. Although the evidence is scarce, the literature did highlight specific system- and organisation-level barriers and enablers that influence practice change, including inter-professional communication and human resource investments. In conclusion, (1) the current evidence on the education and system-level enablers, barriers, and strategies to optimise pressure injury best practices requires further investigation, and (2) multi-faceted, up-stream, evidence-based approaches for pressure injury care are essential to improve health care and patient-related outcomes.