Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales

Psychometric properties of the Braden scale to assess pressure injury risk in intensive care: A systematic review

OBJECTIVE

To analyse the psychometric properties of the Braden scale to assess pressure injury risk in adults in intensive care.

DESIGN

A systematic review was conducted, with literature searches undertaken in five electronic databases. No date limits were applied. Selection, data extraction and risk of bias assessment were completed by two reviewers independently. A customised data extraction template was used, with risk of bias conducted using the COSMIN Risk of Bias checklist. Data were analysed using narrative synthesis.

RESULTS

Thirty-four studies met inclusion criteria. Two studies reported internal consistency with Cronbach's alpha ranging from poor (0.43) to good (0.85). For interrater reliability, only four studies reported intraclass correlation, ranging from 0.66 to 0.96 for Braden sum score. Three studies reported convergent validity, with strong associations found between the COMHON Index (r = 0.70), Cubbin-Jackson scale (r = 0.80), and Norton scale (r = 0.77), but contrasting associations with the Waterlow score (r = 0.22 to 0.72). A large majority of studies reported predictive validity (n = 29), with wide variability. Several studies investigated optimal cut-off scores, with the majority indicating this was in the range of 12-14.

CONCLUSIONS

This review demonstrates inconsistency in the psychometric properties of the Braden scale in ICU settings. Further research is needed to determine suitability of the Braden scale for ICU before it can be recommended as standard for clinical practice, including comparison with other ICU-specific risk assessment tools.

IMPLICATIONS FOR CLINICAL PRACTICE

When used in ICU, the reliability, validity and reported cut-off scores of the Braden scale are variable. As a predictive tool, the scale should be used cautiously. In ICU, the value of the Braden scale resides in its ability to identify patients that are most at risk of developing a pressure injury and to implement preventative measures to mitigate identified risk factors.

Pressure ulcer risk assessment in the ICU. Is it time for a more objective measure?

BACKGROUND

The Braden scale, one of the most widely used risk assessment tools is often criticized when used in the Intensive Care Unit. Most patients in the Intensive Care Unit are at risk of pressure ulcer development meaning that the Braden score will usually indicate high risk for these patients. This study set out to determine the correlation between Sub-Epidermal Moisture measurements and Braden scores among Intensive Care Unit patients.

METHODS

This study employed an observational research design. Braden score was assessed on all study days (1-5), in addition to visual skin assessment and Sub-Epidermal Moisture measurements at the sacrum and heels. Sub-Epidermal Moisture measurements were categorised as low (<0.5), borderline abnormal (≥0.5), and high (≥0.8). Correlation was assessed between Sub-Epidermal Moisture levels and Braden scores.

RESULTS

A total of 53 participants were recruited. The median (interquartile range) baseline Braden score was 9 (9-10) and 81 % (n = 43) of participants were at very high/high risk of pressure ulcer development. Braden scores remained relatively constant over time with little fluctuation in scores. 19 % (n = 10) of patients had normal (<0.5) Sub-Epidermal Moisture delta measurements on enrolment, and all developed abnormal measurements by day 2. There were no significant correlations between Braden scores and Sub-Epidermal Moisture measurements.

CONCLUSION

Although this was not its original intention, a missing link with the Braden scale is that it does not provide information on how patients are responding to the adverse effects of pressure and shear forces. Furthermore, in patients who are critically unwell, most patients are classified as being "at risk" of pressure ulcer development. Therefore, an objective measure of how patients are responding to pressure and shear forces at different anatomical areas is needed.

IMPLICATIONS TO CLINICAL PRACTICE

Sub-Epidermal Moisture measurements can offer more information, not only on identifying those who are at risk, but also how those patients are tolerating this risk at different anatomical sites.

Assessment of pressure injury risk in intensive care using the COMHON index: An interrater reliability study

OBJECTIVES

To assess the interrater reliability of the COMHON (level of COnciousness, Mobility, Haemodynamics, Oxygenation, Nutrition) Index pressure injury risk assessment tool.

DESIGN

Interrater reliability was tested. Twenty-five intensive care patients were each assessed by five different nurse-raters from a pool of intensive care nurses who were available on the days of assessment. In total, 25 nurses participated.

SETTING

Two general and one cardiovascular surgery intensive care units in Istanbul, Turkey.

MAIN OUTCOME MEASURES

Interrater reliability was analysed using intraclass correlations, and standard errors of measurement (SEM) were calculated for sum scores, risk level and item scores. Minimally detectable change (MDC) was also calculated for sum score. Consistency between paired raters was analysed using Pearson's Product Moment Correlation (r) for sum score and Spearman's rho (rs) for ordinal variables.

RESULTS

All assessments were completed in ≤5 min. Interrater reliability was very high [ICC (1,1) = 0.998 (95 % CI 0.996 - 0.999)] with a SEM of 0.14 and MDC of 0.39. Consistency between paired raters was strong for sum and item scores and risk levels (coefficients >0.6). All scale items showed correlations of >.3 with the sum score.

CONCLUSION

The results demonstrate near-perfect interrater reliability. Further research into the psychometric properties of the COMHON Index and its impact on preventative intervention use is warranted.

IMPLICATIONS FOR CLINICAL PRACTICE

Pressure injury risk assessment within intensive care should be setting-specific due to the unique risk factors inherent to the patient population, which are not considered by general pressure injury risk assessment tools. An intensive care-specific pressure injury risk assessment tool was tested and demonstrated high reliability between intensive care nurses. Further research is needed to understand how its use in practice affects preventative intervention implementation and, in turn, how it impacts pressure injury outcomes.

Differentiating Pressure Ulcer Risk Levels through Interpretable Classification Models Based on Readily Measurable Indicators

Pressure ulcers carry a significant risk in clinical practice. This paper proposes a practical and interpretable approach to estimate the risk levels of pressure ulcers using decision tree models. In order to address the common problem of imbalanced learning in nursing classification datasets, various oversampling configurations are analyzed to improve the data quality prior to modeling. The decision trees built are based on three easily identifiable and clinically relevant pressure ulcer risk indicators: mobility, activity, and skin moisture. Additionally, this research introduces a novel tabular visualization method to enhance the usability of the decision trees in clinical practice. Thus, the primary aim of this approach is to provide nursing professionals with valuable insights for assessing the potential risk levels of pressure ulcers, which could support their decision-making and allow, for example, the application of suitable preventive measures tailored to each patient's requirements. The interpretability of the models proposed and their performance, evaluated through stratified cross-validation, make them a helpful tool for nursing care in estimating the pressure ulcer risk level.

Nomogram model on estimating the risk of pressure injuries for hospitalized patients in the intensive care unit

OBJECTIVES

This study aimed to build and validate a nomogram model to estimate the risk of pressure injuries in intensive care unit patients.

DESIGN

Multicenter prospective cohort study.

SETTING

33 tertiary hospitals in the Gansu Province, China.

MEASUREMENTS AND MAIN RESULTS

This study included 6420 patients between April 2021 to October 2022 from an information platform of pressure injury risk management called the "Long Hu Hui." Univariate and multivariate logistic regression analyses identified pressure injury risk factors to be included in the nomogram. The resulting nomogram was tested for calibration discrimination, and clinical usefulness. Of the included patients, 77 developed pressure injuries, representing an incidence rate of 1.2 %. Analysis of binary logistic regression revealed that the estimation nomogram included weight loss greater than 5 kg in the last three months, pneumotomy cannula, thoracic catheter, isoproterenol, norepinephrine, abnormal skin color, ruptured erythema, stroke, increased body temperature and nonspecific patients (specific patients include paralysis, unconsciousness, dementia, forced body position). The area under the receiver operating characteristic curve for the training cohort was 0.806 (95 % CI 0.755-0.857), and the AUC of the text cohort was 0.737 (95 % CI 0.574-0.901). The model has excellent calibration in both the training cohort (H-L test: χ2 = 6.34, P = 0.61) and the text cohort (H-L test: χ2 = 4.50, P = 0.81). Furthermore, the decision curve analysis revealed the preferred net benefit and the threshold probability in the estimation nomogram.

CONCLUSIONS

The nomogram model accurately estimated the risk of pressure injuries among intensive care patients, it should be used to inform risk assessment and facilitate early intervention strategies in future practice.

IMPLICATIONS FOR CLINICAL PRACTICE

The nomogram allows intensive care providers to dynamically assess the patient's risk of pressure injuries and to implement more targeted interventions accordingly.

Sub epidermal moisture measurement and targeted SSKIN bundle interventions, a winning combination for the treatment of early pressure ulcer development

This study aimed to investigate the impact of sub epidermal moisture (SEM) measurement and targeted pressure ulcer (PU) prevention, versus visual skin assessment and usual care, on mean SEM delta scores and early pressure ulcer development in acute hospital patients. A quantitative quasi-experimental observational approach was used. A total of 149 at risk acute hospital patients took part, 78 treatment, and 71 control. SEM deltas were recorded daily for a maximum of 5 days using the SEM Scanner (Bruin Biometrics LLC, Los Angeles, California), on three sites: the sacrum, the right heel, and the left heel, with enhanced and targeted PU prevention interventions occurring in those with an elevated SEM delta scores in the treatment group. Intention to treat analysis was used to guide the final composition of results. SEM PU represents PU development as identified by 2 days of sustained abnormal SEM delta scores, ≥0.5, after day one. The mean number of days completed by participants was just under 4 days, participants had many different comorbidities, with the most common being: hypertension, cancer, and chronic obstructive pulmonary disease. Results showed that following the introduction of SEM guided targeted treatments, participants in the treatment group yielded a statistically significant reduction in mean SEM delta scores (MD: 0.49; 95% CI: 0.59, 0.39; P < .0001), and in the odds of developing a SEM PU (OR: 0.59, 95% CI: 0.24 to 1.00; P = .05). In the treatment group, none of the participants developed a visual PU, whereas, in the control group, 1.41% (n = 1/71) developed a visual PU. Based on all the results, the following is concluded, (1). There was a greater reduction in mean SEM delta scores among those cared for using SEM measurement and targeted PU prevention, versus those cared for using visual skin assessment and usual care, and (2). the mean SEM delta scores was statistically significantly lower at the study end for those who received targeted treatments based on abnormal SEM scores. More research is now needed in other and larger at-risk groups to further validate what was found in this study.

Compliance with preventive measures recommended by an international study group for pressure injuries in adult critically ill patients

The objective of this cross-sectional descriptive study is to analyse the degree of compliance with the preventive measures for pressure injuries reported by an International Study Group in a cohort of adult critically ill patients. The level of risk of developing pressure injuries was determined using the Conscious level, Mobility, Hemodynamics, Oxygenation and Nutrition (COMHON) index. According to the level of risk, the preventive measures applied to each patient and scores on the different components of the index were recorded. Number, location and degree of pressure injuries were registered. Seventy-three patients (male: 68%) with an acute physiology and chronic health evaluation (APACHE) II: 12,1 ± 6,2 and 56,1% of them with invasive mechanical ventilation. The prevalence of pressure injuries was 21,9%, with 43,7% of sacral location and 75% of grade II. The level of risk using the COMHON index was distributed between low 30,1%, intermediate 23,3% and high 46,6%. The compliance range from 0% (offloading heel devices) to the use of active mattress and incontinence pads (100%). Regarding repositioning the degree of compliance varies (from 20% to 80%) according if patients with contraindications (4 points in subscale of Mobility) or those with the capacity to mobilise themselves (2 points in subscale of Mobility) are included in the denominator. We have found that in our ICU there is a wide range of compliance with the use of the preventive measures recommended by the International Study Group. Some of them are related not by the general score of the COMHON scale, but to that obtained in its subscale components.

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.

Moving average as a method of assessing risk of pressure injury using the COMHON index (Conscious level, Mobility, Hemodynamic, Oxygenation, Nutrition) for patients in intensive care units

BACKGROUND

Moving average is the continuously updated arithmetic mean of the pressure injury (PI) risk score values measured with the COMHON Index (Conscious level, Mobility, Hemodynamics, Oxygenation, Nutrition).

OBJECTIVE

The objective of this study was to validate the moving average as a method to measure the level of risk of PI.

METHOD

This is a cohort study of adult patients admitted for a duration of more than 24 h in an intensive care unit (ICU) of a tertiary-level university hospital, between June 1, 2018, and December 31, 2019. The risk of PI was obtained with the COMHON Index, and its 3-day moving average was used to monitor the risk of PI. To assess the predictive ability of the moving average score, a receiver operating characteristic curve analysis was performed, obtaining the area under the curve, and the Youden Index to determine the optimal cut-off point of the PI risk moving average score using the COMHON Index.

RESULTS

A total of 1335 patients (94.6% of admissions) were included, and 82 developed PI (cumulative incidence of 6.1%) in the 18 months of the study. The highest incidence of PI was in the sacrum (49%) followed by the heel (17.6%). The median age was 65 (54-73) years, and the median length of stay was 3.8 (1.9-9) days. The moving average score had an area under the receiver operating characteristic curve of 87% (95% confidence interval: 85%-89%), with a cut-off point of the moving average score ≥11, and the negative predictive value was 99.6%.

CONCLUSIONS

The moving average score combined with a validated scale is a useful method to predict potential PI of patients admitted to the ICU. Its use is suggested for decision-making during the implementation of the care plan related to the prevention of PI in patients admitted to the ICU.

Biomarkers for the early detection of pressure ulcers in the intensive care setting: A comparison between sub-epidermal moisture measurements and interleukin-1α

Pressure ulcer (PU) prevention in the intensive care unit (ICU) is an important clinical issue as critically unwell patients are at high risk of developing PUs. However, current methods of PU detection are limited, especially for early detection. This study aimed to establish the correlation between Interleukin-1α (IL-1α)/total protein (TP) and sub-epidermal moisture (SEM) measurements in the early identification of PUs in ICU patients. This study employed an observational research design using the STROBE guidelines. Following ethical approval, 53 participants were recruited and sebum was obtained using Sebutape from weight-bearing areas (sacrum, heels and a control site). SEM measurements were taken from the same anatomical sites. Both measures were taken at the same time and participants were followed up for 5 days, or until discharge or death. Correlations between SEM delta measurements, IL-1α, TP and PU incidence and other demographic information were explored using Spearman's correlation for data not normally distributed, and Pearson's R correlation coefficient for normally distributed data. Mean baseline SEM delta measurements indicate abnormal readings for all anatomical sites except the control site, consistent with previous studies. Mean baseline IL-1α/TP readings were higher for the sacrum versus both heels and, on average, readings were higher for the control site versus all other anatomical locations. This is conflicting, given that the control site was non-weight bearing. There were very weak or weak correlations between SEM delta measurements and IL-1α/TP readings. SEM measurements are quick and easy to obtain and results are instant, however Sebutape sampling takes significantly longer and is challenging to conduct among haemodynamically unstable patients. Obtaining SEM measurements is more practical and feasible than Sebutape sampling to assess for the presence of inflammation.

Pressure Injuries and Management after Spinal Cord Injury

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Biomarkers for the early detection of pressure injury: A systematic review and meta-analysis

BACKGROUND

Pressure injury imposes a significant burden for patients and healthcare systems and the majority of pressure injuries are preventable. The early identification of pressure injury is critical for its prevention. As an objective measure, biomarkers have preliminarily shown the potential to identify individuals at risk for developing pressure injury before it is visually observed to occur. However, these results have not been synthesized.

OBJECTIVE

To assess and synthesise the predictive effect of different biomarkers in the early detection of pressure injury formation.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, CINAHL Complete and the Cochrane Library were comprehensively searched for articles up to June 2021. No restrictions were applied to study design type, language, country, race or date of publication.

REVIEW METHODS

Two reviewers independently extracted data from all original eligible studies using a specified data extraction form, resolved disagreements through discussion and the involvement of an additional reviewer. Methodological quality of all included studies was independently appraised by two authors with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and the Newcastle-Ottawa Quality Assessment Scale (NOS). Heterogeneity of each study was estimated using the I² statistic, and the data was synthesized using StataSE15.

RESULTS

Eight observational studies involving 10595 participants were included. The overall pooled area under curve (AUC) and the 95% confidence intervals (CIs) of Serum albumin (Alb) was 0.66(0.62-0.70), and the Serum haemoglobin (Hb) was 0.67(0.60-0.74). The AUC and 95% CI of C-reactive protein (CRP) was 0.62(0.50-0.74), Braden score was 0.56 (0.429-0.691), Waterlow score was 0.729(0.654-0.803), Alb with Waterlow was 0.741(0.694-0.787), and the combination of Hb, CRP, Alb, Age and Gender was 0.79(0.682-0.898). Besides, the chemokine interferon-γ-induced protein of 10kd/CXCL10, cytokine interferon-α, tumor necrosis factor-alpha (TNF-α), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-15 (IL-15) and combination of creatine kinase (CK), myoglobin (Mb), heart-type fatty acid binding protein (H-FABP) and CRP may prove potential for detecting pressure injury.

CONCLUSION

The findings suggest the combination of Hb, CRP, Alb, Age and Gender is superior to other biomarkers. However, the predictive effect of biomarkers needs to be confirmed by more researches and patient-level data.

Effects of vasopressor agents on the development of pressure ulcers in critically ill patients: a systematic review

OBJECTIVE

The primary objective of this systematic review was to determine the effect of vasopressor agents on the development of pressure ulcers (PUs) among critically ill patients in intensive care units (ICUs). The secondary outcome of interest was length of stay in the ICU.

METHOD

A systematic review was undertaken using the databases searched: Medline, Embase, CINAHL and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to formulate the review. Data were extracted using a predesigned data extraction table and analysed as appropriate using RevMan. Quality appraisal was undertaken using the EBL Critical Appraisal Tool.

RESULTS

The inclusion criteria were met by 13 studies. Two studies provided sufficient data to compare the number of patients who developed a PU with and without the use of vasopressors. Consistently, within these two studies, being treated with a vasopressor increased the likelihood of PU development. RevMan analysis identified that shorter duration of administration of vasopressors was associated with less PU development (mean difference (MD) 65.97 hours, 95% confidence interval (CI): 43.47-88.47; p=0.0001). Further, a lower dose of vasopressors was also associated with less PU development (MD: 8.76μg/min, 95% CI: 6.06-11.46; p<0.00001). Mean length of stay increased by 11.46 days for those with a PU compared to those without a PU (MD: 11.46 days; 95% CI: 7.10-15.82; p<0.00001). The overall validities of the studies varied between 45-90%, meaning that there is potential for bias within all the included studies.

CONCLUSION

Vasopressor agents can contribute to the development of PUs in critically ill patients in ICUs. Prolonged ICU stay was also associated with pressure ulcers in this specific patient group. Given the risk of bias within the included studies, further studies are needed to validate the findings of this review paper.

Translation and piloting of the Chinese Mandarin version of an intensive care-specific pressure injury risk assessment tool (the COMHON Index)

Objective

Methods

Results

Conclusions

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings.

REVIEW METHOD USED

This is a systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Five databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019.

REVIEW METHODS

From an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care-specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate.

RESULTS

Overall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I² = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I² = 0%) and heel (risk ratio = 0.31, p = 0.02; I² = 0%) prophylactic dressings for pressure injury prevention.

CONCLUSIONS

Only prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care-specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.

Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review

BACKGROUND

Whilst performing a pressure injury risk assessment is not in itself preventive, risk status identification is critical to inform the judicious implementation of prevention strategies. Risk assessment is mostly undertaken using a structured tool informed by clinical judgement, though there is a perception that use of clinical judgement alone may be sufficient.

OBJECTIVES

Within acute hospital settings, to identify differences in outcomes (risk status, preventive interventions) following nursing assessment of pressure injury risk when using a structured assessment tool compared to clinical judgement.

DESIGN

Systematic review.

DATA SOURCES

EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus, Web of Science, Ovid EMBASE.

METHODS

Primary research relevant to the objectives was eligible for inclusion. Databases were searched in February 2021 (limits: date 2010-2020, English language, adults). Two reviewers undertook the review process, with a third as arbitrator. Appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Included studies are synthesised narratively. Reporting is in accordance with the PRISMA Statement.

RESULTS

Five moderate to high-quality studies were included. Synthesis was limited by heterogeneity. Several risk assessment tools and methods of clinical judgement were used. Three studies reported pressure injury risk status using both assessment approaches, but in only one did nurses undertake both. Risk status, as identified by each method, varied and was sometimes contradictory. Three studies reported some elements of preventive intervention prescription and/or implementation following risk assessment, but comparison between approaches was limited.

CONCLUSIONS

Some research suggests that risk status varies across different methods of pressure injury risk assessment, but it is unclear what impact this has on preventive intervention use. Risk status was not well linked to preventive interventions. Research is warranted to examine the influence that each approach to risk assessment alone and combined has on identified risk and preventive intervention prescription and implementation.

REGISTRATION

A protocol was prospectively registered with PROSPERO (CRD42021224747).

Frequency of and risk factors for intensive care unit-acquired sacrum pressure injuries in critically ill patients: A multicenter cross-sectional study in China

RATIONALE AIMS AND OBJECTIVES

Hospital-acquired pressure injuries (HAPI) prolong hospital stays and are an important health problem worldwide. The aim of this study was to assess the frequency of and risk factors for intensive care unit (ICU)-acquired pressure injuries (IAPI) on the sacrum in critically ill patients in China.

METHODS

We performed a multicenter, cross-sectional survey of IAPI on the sacrum in 23 adult ICUs in 19 hospitals in China. Data for 421 critically ill patients were collected on December 13, 2019, and January 13, 2020, including patient characteristics, physiological, and clinical information. Logistic regression was used to analyze the risk factors for IAPI on the sacrum in the ICU.

RESULTS

Forty-one patients presented sacrum pressure injuries in the ICU, with a frequency of 9.74%. Risk factors that significantly increased the risk of IAPI on the sacrum were lower body mass index (BMI, odds ratio [OR] = 1.115, confidence interval [CI]: 1.011-1.229, P = .029), chronic obstructive pulmonary disease (COPD, OR = 3.183, CI: 1.261-8.037, P = .014), multiple organ dysfunction syndrome (MODS, OR = 2.670, CI: 1.031-6.903, P = .043), and a lower Braden risk score (OR = 1.409, CI: 1.197-1.659, P < .001).

CONCLUSION

Lower BMI, COPD, MODS, and lower Braden risk score are independent risk factors for sacrum IAPI in China.

The Effect of Padded Adhesive Dressing and Static Body Position on Sacral Interface Pressure

OBJECTIVES

Padded adhesive bandages are frequently used in the inpatient setting for sacral pressure injury prevention, but it is unclear whether they truly decrease interface pressure. We hypothesized such devices reduce sacral peak interface pressure in the supine position, which would be further reduced in 30-degree reclined and upright seated positions.

METHODS

Study participants rested with their sacrum on a pressure-sensing mat, in 3 positions, for 30 seconds each: (1) sitting upright; (2) supine; and (3) supine against 30-degree wedge. Measurements were made with and without a padded adhesive bandage overlying the sacrum. Age, sex, and body mass index (BMI) were collected. These variables were entered sequentially, in an a priori order to construct a linear mixed-effects model.

RESULTS

Forty healthy adults participated. After controlling for by-subject variation, age, and sex, BMI did not influence peak sacral pressure (P = 0.22), although the effect of body position was significant (P < 0.01). Subsequent addition of padded adhesive dressing was nonsignificant (P = 0.17); sacral peak pressure was similar with a padded adhesive dressing (247.8 ± 147.3 mm Hg) or without (mean ± standard deviation = 229.8 ± 127.7 mm Hg). Lastly, there was no significant interaction between BMI and body position (P = 0.11).

CONCLUSIONS

Padded adhesive bandages did not reduce interface pressure in any position. Sacral pressure was highest in the supine position and was not specifically affected by BMI. If padded bandages provide clinically significant reduction in pressure injury incidence, it is not simply through the reduction of interface pressure.

Pressure wounds in a cohort of critical patients: incidence and associated factors

AIM

To assess the incidence and factors associated with pressure wounds in patients of a Brazilian clinical and surgical Intensive Care Center (composed of three Intensive Care Units).

METHOD

Cohort monitored for clinical and therapeutic variables in an Intensive Care Center. Cox's Multiple Regression was employed, establishing the number of days until the first pressure injury as a time variable; the omnibus test was also performed.

RESULTS

178 patients, 64 (36%) developed at least one pressure wound. The independent variables for the risk of pressure wounds were: Braden <13 (HR: 10.6; 95% CI: 2.5-43.7), history of previous stroke (HR: 2.6; 95% CI: 1.3-5.0), age> 60 years (HR: 2.0; 95% CI: 1.2-3.5), nothing by mouth time (HR: 1.06; 95% CI 1.02 -1.10) and physical therapy days (HR: 0.81; 95% CI: 0.73-0.91).

CONCLUSION

Pressure wounds were incident. Braden <13 points, history of previous strokes, being elderly, and time in nothing by mouth were shown to be independent risk factors for pressure wounds. The days of exposure to physical therapy were protective. These findings corroborate recommendations to monitor the frequency of pressure wounds and to establish protective measures based on local indicators.

Value of pressure injury assessment scales for patients in the intensive care unit: Systematic review and diagnostic test accuracy meta-analysis

OBJECTIVES

To review and examine the evidence of the value of pressure injury risk assessment scales in intensive care patients.

RESEARCH METHODOLOGY

We searched MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, China Biomedical Literature Service System, VIP Database and CNIK from inception to February 2019. Two reviewers independently assessed articles' eligibility and risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-II (QUADAS-2). We used a hierarchical summary receiver operating characteristics (HSROC) model to conduct the meta-analysis of diagnostic accuracy.

RESULT

Twenty-four studies were included, involving 16 scales and 15,199 patients in intensive care settings. Results indicated that the top four risk assessment scales were the Cubbin & Jackson Index (SEN = 0.84, SPE = 0.84, AUC = 0.90), the EVRUCI scale (SEN = 0.84, SPE = 0.68, AUC = 0.82), the Braden scale (SEN = 0.78, SPE = 0.61, AUC = 0.78), the Waterlow scale (SEN = 0.63, SPE = 0.46, AUC = 0.56). The Norton scale and the other eleven scales were tested in less than two studies and need to be further researched.

CONCLUSION

The Braden scale, most frequently used in hospitals, is not the best risk assessment tool for critically ill patients. The Cubbin & Jackson Index has good diagnostic test accuracy. However, low quality of evidence and important heterogeneity were observed.

The Random Forest Model Has the Best Accuracy Among the Four Pressure Ulcer Prediction Models Using Machine Learning Algorithms

Purpose

Build machine learning models for predicting pressure ulcer nursing adverse event, and find an optimal model that predicts the occurrence of pressure ulcer accurately.

Patients and Methods

Retrospectively enrolled 5814 patients, of which 1673 suffer from pressure ulcer events. Support vector machine (SVM), decision tree (DT), random forest (RF) and artificial neural network (ANN) models were used to construct the pressure ulcer prediction models, respectively. A total of 19 variables are included, and the importance of screening variables is evaluated. Meanwhile, the performance of the prediction models is evaluated and compared.

Results

The experimental results show that the four pressure ulcer prediction models all achieve good performance. Also, the AUC values of the four models are all greater than 0.95. Besides, the comparison of the four models indicates that RF model achieves a higher accuracy for the prediction of pressure ulcer.

Conclusion

This research verifies the feasibility of developing a management system for predicting nursing adverse event based on big data technology and machine learning technology. The random forest and decision tree model are more suitable for constructing a pressure ulcer prediction model. This study provides a reference for future pressure ulcer risk warning based on big data.

Incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care: A systematic review and meta-analysis

BACKGROUND

Pressure injury is recognised as an adverse event occurring in healthcare settings. Patients in intensive care are at high risk of developing a pressure injury. Cardiac patients are also among those at higher risk.

OBJECTIVES

To systematically assess the incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care.

DESIGN

Systematic review and meta-analysis of incidence and prevalence REVIEW METHODS: Articles published in English between 2009 and 2018, reporting pressure injury as a primary outcome were selected based on inclusion criteria. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. A random effects meta-analysis was conducted. Sub-group meta-analyses were conducted to investigate potential causes of heterogeneity.

RESULTS

Fifteen studies met the criteria for inclusion in the systematic review, of which 14 were incidence studies. Heterogeneity was significant and there was large observed variance between studies. The 95% confidence interval of cumulative incidence across all 14 studies, with an overall sample size of 6371, was 9.8-25.6%. In 11 studies that included all-stage pressure injury the 95% confidence interval was 8.3-28.3%. In seven studies in which Stage 1 pressure injury was excluded, the 95% confidence interval was 5.8-22.7%. In the single prevalence study included, which excluded Stage 1 pressure injury, prevalence was 8.8%.

CONCLUSIONS

The incidence of pressure injury in cardiac intensive care patients was similar to that found in general intensive care patients. However, our results suggest that the incidence may be significantly higher in cardiac surgical patients admitted to intensive care. There were significant differences across the various studies in the ways in which data were collected and reported. Further well-designed studies are required to better understand incidence in this population, using standardised methods of data collection and reporting.

The economic impact of pressure ulcers among patients in intensive care units. A systematic review

BACKGROUND

The incidence and prevalence of pressure ulcers in critically ill patients in intensive care units (ICUs) remain high, despite the wealth of knowledge on appropriate prevention strategies currently available.

METHODS

The primary objective of this systematic review was to examine the economic impact of pressure ulcers (PU) among adult intensive care patients. A systematic review was undertaken, and the following databases were searched; Medline, Embase, CINAHL, and The Cochrane Library. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was used to formulate the review. Quality appraisal was undertaken using the Consensus on Health Economic Criteria (CHEC)-list. Data were extracted using a pre-designed extraction tool, and a narrative analysis was undertaken.

RESULTS

Seven studies met the inclusion criteria. Five reported costs associated with the prevention of pressure ulcers and three explored costs of treatment strategies. Four main PU prevention cost items were identified: support surfaces, dressing materials, staff costs, and costs associated with mobilisation. Seven main PU treatment cost items were reported: dressing materials, support surfaces, drugs, surgery, lab tests, imaging, additional stays and nursing care. The overall validities of the studies varied between 37 and 79%, meaning that there is potential for bias within all the included studies.

CONCLUSION

There was a significant difference in the cost of PU prevention and treatment strategies between studies. This is problematic as it becomes difficult to accurately evaluate costs from the existing literature, thereby inhibiting the usefulness of the data to inform practice. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Relationship Between Prescription and Documentation of Pressure Injury Prevention Interventions and Their Implementation: An Exploratory, Descriptive Study

BACKGROUND

Formal assessment by nurses of a patient's pressure injury (PI) risk level is often highlighted as being key to PI prevention. However, if no action is taken to address the determined risk (i.e., if appropriate preventative interventions are not implemented), the patient remains vulnerable to PI development, and the assessment process is rendered pointless.

AIM

To explore the relationship between the prescription (planning) and implementation of PI preventative interventions by nurses following formal risk assessment.

METHODS

Using an exploratory, descriptive design, the charts and bedside areas of 200 adult patients admitted across four hospital wards were examined. Data collected included PI risk level, documented prescribed preventative interventions, and interventions for which there was evidence of implementation.

RESULTS

Of the final sample (n = 187), 66.8% of cases were categorized as being "at-risk" or above. As the risk category of patients increased, proportionately more patients in each category were prescribed each intervention. However, in most cases, significantly fewer interventions were actually implemented than were prescribed, except for several interventions that were implemented in more cases than were prescribed. There were 14 cases, including four at-risk and three high-risk patients, in which no preventative interventions were prescribed, while 88.7% of not at-risk patients had (unnecessary) preventative interventions prescribed.

DISCUSSION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. The results indicate a significant mismatch between these two steps of PI prevention.

LINKING EVIDENCE TO ACTION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. A significant mismatch between these two steps of PI prevention was evident. Following patient risk assessment, there should be a greater focus on appropriate preventative intervention prescription (planning) with regular review and audit to help ensure that interventions are implemented as prescribed. Improved implementation of preventative interventions should, in turn, help to reduce hospital-acquired pressure injuries.

International consensus on pressure injury preventative interventions by risk level for critically ill patients: A modified Delphi study

The aim of this modified Delphi study was to determine a minimum pressure injury preventative intervention set for implementation relative to critically ill patients' risk level. Preventative interventions were identified via systematic review, risk levels categorised by an intensive-care-specific risk-assessment-scale (COMHON Index), and panel members (n = 67) identified through an international critical care nursing body. Round 1: panel members were asked to rate implementation of 12 interventions according to risk level (low, moderate, high). Round 2: interventions were rated for use at the risk level which received greatest round 1 support. Round 3: interventions not yet achieving consensus were again rated, and discarded where consensus was not reached. Consensus indicated all patients should receive: risk assessment within 2-hours of admission; 8-hourly risk reassessment; and use of disposable incontinence pads. Additionally, moderate- and high-risk patients should receive: a reactive mattress support surface and a heel off-loading device. High-risk patients should also receive: nutritional supplements if eating orally; preventative dressings (sacral, heel, trochanteric); an active mattress support surface; and a pressure-redistributing cushion for sitting. Repositioning is required at least 4-hourly for low-risk, and 2-hourly for moderate- and high-risk patients. Rigorous application of the intervention set has the potential to decrease pressure injuries in intensive care.

Development and validation of an ICU-specific pressure injury risk assessment scale

BACKGROUND

Critically ill patients are at high risk for pressure injury (PI) due to critical illness combined with multiple interventions and therapies. It is hence important to gain more knowledge about the risk factors associated with pressure injury development and methods for decreasing its prevalence.

AIMS

To develop and validate a clinical useful ICU-specific PI risk assessment scale based on the RAPS.

METHOD

The study was designed as a prospective instrument development and validation study. The Risk Assessment Pressure Ulcer Scale (RAPS), which in Sweden is a commonly used PI risk assessment scale, was used as a starting point. Development was then performed in different steps; adaption of items and response options to ICU care, discussion with ICU staff members to enhance clinical relevance and usability, test of interrater reliability, revision of instrument, a new test with 300 patients followed by statistical evaluation.

RESULTS

The final version of the RAPS-ICU consists of six items: failure of vital organs, mobility, moisture, sensory perception, level of consciousness and special treatment in the form of mechanical ventilation, continuous dialysis and/or inotropic drugs. A total score was reached by summing all responses. Each of the items was found to be significant associated with PI development as well as the total score (p < 0.001). The total score also showed a high interrater reliability (ICC = 0.96), good sensitivity and acceptable specificity with AUC = 0.71 and ICU staff perceived the RAPS-ICU as relevant and easy to use in clinical practice.

CONCLUSION

The RAPS-ICU is a valid and clinically useful tool to identify patients at risk to develop pressure injury at ICU.

Comparison of four pressure ulcer risk assessment tools in critically ill patients

BACKGROUND

Critically ill patients are at a higher risk of developing pressure ulcers (PUs) than non-critically ill patients. Tools that aid in the early identification of those who are most at risk of PUs could help health care providers deliver early interventions and reduce unfavourable outcomes.

AIMS

To compare the validity of four PU risk tools (the Braden scale, the Braden [ALB] scale, the CALCULATE, and the COMHON index) and to demonstrate the optimal cut-off points for each tool in critically ill patients.

DESIGN

This was a prospective descriptive study.

METHOD

This study was conducted in the intensive care units (ICUs) of a tertiary care hospital in Thailand from January to April 2019. Baseline characteristics were collected at admission to the ICUs. Skin assessment was evaluated every 24 hours. PU assessment scores were collected every 72 hours. Receiver operating characteristic curves were used to compare the performance of the tests in predicting PUs.

RESULTS

A total of 288 patients were recruited. The incidence of PUs was 11.1%. The Braden (ALB) scale performed the best based on the area under the receiver operating characteristic curves (area under curve 0.74), followed by the CALCULATE (area under curve 0.71), the Braden (area under curve 0.67) scale, and the COMHON (area under curve 0.61) index. At the optimal cut-off point, the Braden (ALB) scale (≤13)) and the CALCULATE (≥3) were similar in terms of performance with an area under the curve of 0.69.

CONCLUSION

The Braden (ALB) performed the best at predicting PU development in ICU patients.

RELEVANCE TO CLINICAL PRACTICE

The validity of all four PU risk tools was limited in Thai patients. The scales should thus be used in conjunction with clinical judgement to provide optimal outcomes. The development of better assessment tools for the prediction of PUs is required.

Root Cause Analysis for Hospital-Acquired Pressure Injury

Root cause analysis (RCA) is a systematic process for identifying the causes of an adverse occurrence or combined with an approach for a response designed to prevent recurrences. This method may be used for continuous quality improvement in a facility or health system. Root cause analysis can aid nurses and hospital risk managers to determine how the system can improve to reduce the number and severity of pressure injuries. The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.

Prescription of pressure injury preventative interventions following risk assessment: An exploratory, descriptive study

This exploratory, descriptive study aimed to identify and describe the pressure injury preventative interventions prescribed by nurses following the assessment of a patient's pressure injury risk and to compare the prescribed interventions relative to the assessed risk level. A total of 200 inpatients in a tertiary Australian hospital were included. Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. Most patients were assessed as not being at risk, with the largest group of at-risk patients assessed as being at high risk. Some not-at-risk patients were prescribed interventions intended for those at risk, while prescription rates of preventative interventions recommended for those at any level of risk were variable (6%-64%). Significant associations were found between assessed pressure injury risk and preventative intervention prescription. Preventative intervention prescription was inadequate, potentially exposing some patients to pressure injury. However, the association between intervention prescription and risk level suggests that nurses are prescribing interventions relative to risk. A more structured approach to intervention prescription according to risk level, such as a care bundle, may help to improve nurses' preventative intervention prescription and ensure that all at-risk patients receive appropriate preventative interventions.

Predictive ability of the EVARUCI scale and COMHON index for pressure injury risk in critically ill patients: A diagnostic accuracy study

BACKGROUND

Hospital-acquired pressure injuries are a costly and largely preventable complication occurring in a variety of acute care settings. Patients admitted to the intensive care unit are at greater risk of developing pressure injuries.

OBJECTIVE

To determine whether the efficiency of scales to measure pressure injury risk increase when a continuously updated 3-day moving average method is used.

METHODS

With a retrospective cohort design we recruited 3085 patients treated between June 2011 and February 2015 in the intensive care unit of a tertiary level university hospital. The present study included 2777 patients admitted to the Intensive Care Unit of the Hospital Universitario de Canarias, Spain. Patients were evaluated daily with two scales to measure pressure injury risk: the Current Risk Assessment Scale for Pressure injury in Intensive Care scale (EVARUCI scale) and the Conscious level-Mobility-Haemodynamics-Oxygenation-Nutrition Index (COMHON). The moving average was used to create a series of three day averages from the complete time-data set. The moving average method was used to analyze data points by creating series of averages of three days subsets of the time-data set. We calculated the efficiency of the method as the product of positive (PPV) and negative predicted values (NPV) for each scale.

RESULTS

The efficiency using the moving average method was: PPV x NPV=0.483×0.907=0.438 (standard deviation=0.059), for EVARUCI Scale, and. PPV x NPV=0.552×0.806=0.445 (standard deviation=0.075) for COMHON Index.

CONCLUSIONS

The efficiency using the moving average method was higher, than the efficiency of other methods previously reported (0.360±0.009 on average). The present study provides a useful procedure for nurses in clinical practice to assess whether a particular patient is protected against the appearance of pressure injury. The instrument should be used focusing on negative predictive value to indicate protection against pressure injury.

Psychometric Testing of INTEGRARE, an Instrument for the Assesment of Pressure Ulcer Risk in Inpatients

PURPOSE

The aim of this study is to evaluate the psychometric properties of INTEGRARE, an instrument based on Nursing Outcome Classification.

METHOD

A multicenter, cross-sectional, methodological design was used.

FINDINGS

The study included 3,835 patients. Internal consistency α = 0.86. Confirmatory factor analysis demonstrated the unidimensionality of the scale, indicating a good model fit (CMIN/DF = 4; GFI, CFI, NFI, IFI = 0.999; RMSEA = 0.028).

CONCLUSIONS

INTEGRARE is a valid and reliable instrument with high sensitivity, specificity, and diagnostic accuracy in measuring pressure ulcer (PU) risk in inpatients.

IMPLICATIONS FOR NURSING PRACTICE

This instrument allows us to know the effectiveness of nursing interventions, providing evidence for the validation of the diagnosis Risk for pressure ulcer (00249) as well as on health outcomes, due to the fact that PUs are nursing-sensitive outcomes.

OBJETIVO

Evaluar las propiedades psicométricas de INTEGRARE, un instrumento basado en la Clasificación de Resultados de Enfermería. MÉTODO: Se optó por un diseño transversal multicéntrico.

RESULTADOS

El estudio incluyó a 3,835 pacientes. Consistencia interna α = 0.86. El análisis factorial confirmatorio demostró la unidimensionalidad de la escala, indicando un buen ajuste del modelo (CMIN/DF = 4; GFI, CFI, NFI, IFI = 0.999; RMSEA = 0.028).

CONCLUSIONES

INTEGRARE es un instrumento válido y fiable con alta sensibilidad, especificidad y precisión diagnóstica en la medición de riesgo de úlcera por presión (UPP) en pacientes hospitalizados. IMPLICACIONES PARA LA PRÁCTICA ENFERMERA: Este instrumento nos permite conocer la efectividad de las intervenciones enfermeras, aportando evidencia para la validación del diagnóstico Riesgo de úlcera por presión (00249), así como sobre los resultados de salud, debido a que las UPP son resultados sensibles a la práctica enfermera.

Validity of the Braden Scale in grading pressure ulcers in trauma and burn patients

BACKGROUND

Pressure ulcers are a costly hospital-acquired condition in terms of clinical outcome and expense. The Braden Scale was developed in 1987 as a risk scoring method for pressure ulcers and uses six different risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A score of ≤18 is considered high risk. To date, research on the utility of the Braden Scale has focused on general medicine and nontrauma/burn surgery patients. We hypothesize that the Braden Scale does not accurately discriminate who will get a pressure ulcer among trauma and burn patients.

METHODS

We collected data from medical records regarding documented Braden scores and presence of pressure ulcers regardless of staging. Patients with ulcers present on admission were excluded from analysis. For each patient, the lowest Braden score documented before the occurrence of the pressure ulcer was determined. A logistic regression was used to estimate odds ratios and associated 95% confidence intervals for the association between pressure ulcer likelihood and lowest Braden Scale measurement. To determine the discriminatory ability of the Braden Scale on pressure ulcer risk, four measures of performance (i.e., sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio) were calculated for four nonmutually exclusive groups: a Braden Scale measurement ≤18, ≤14, ≤12, and ≤9.

RESULTS

From 2011 through 2014, a total of 2660 patients were admitted to the trauma/burn intensive care unit. Of these patients, 63 (2.3%) subsequently developed a pressure ulcer. A Braden Scale of ≤18 as the threshold for being at-risk of pressure ulcer had a sensitivity of 100% and specificity of 6%, whereas a Braden Scale of ≤9 had a sensitivity of 28.6% and a specificity of 90%. For all Braden Scale measurements, the positive likelihood ratio never reached the value of 10 that suggests high likelihood of an ulcer.

CONCLUSIONS

The Braden scale has mediocre discriminatory ability among the trauma/burn population. In addition, the low positive likelihood ratio suggests that the Braden scale may not be a useful clinical tool as it may result in unnecessary expenditure of time and personnel resources in preventing pressure ulcer formation.

Evaluation of a formal care worker educational intervention on pressure ulceration in the community

AIMS AND OBJECTIVES

To develop and evaluate an educational intervention for formal care workers on pressure ulceration in the community.

BACKGROUND

Pressure ulcers are a major burden to health care and with an ageing population likely to increase. Formal care workers are ideally placed to identify high risk but lack standardised educational provision.

DESIGN

An insider approach to action research in one provider organisation, November 2014-May 2015.

METHODS

Number and categorisation of pressure ulcers, within three community nursing teams before and four months after intervention was delivered to a purposive sample (n = 250) of formal care workers, were assessed and the taught element evaluated using a questionnaire and verbal feedback.

RESULTS

Total number of pressure ulcers reduced from 28-20, category II, 19-11, III unchanged at 6 and IV from 2-0 following the educational intervention. Key risk factors included impaired mobility (71%), urinary incontinence (61%) and previous pressure damage (25%), and 71% had formal care worker input. The intervention was highly rated 4·95/5 by 215 (86%) formal care workers in the evaluation questionnaire.

CONCLUSIONS

Formal care workers receive little, if any, education on pressure ulceration. An educational intervention can have a positive effect within community care, with the potential to reduce direct costs of care. However, a standardised approach to education is required; an urgent review of the education provision to formal care workers, in the UK and around the world, is therefore essential if the potential that formal care workers offer is to be realised.

RELEVANCE TO CLINICAL PRACTICE

Formal care workers are ideally placed to help identify and alert healthcare professionals about patients at high risk of developing pressure ulcers. If this potential is to be realised, a standardised approach to education is required.

Effects of gelatin sponge combined with moist wound-healing nursing intervention in the treatment of phase III bedsore

Pressure sore pertains to tissue damage or necrosis that occurs due to lack of adequate nutrition following long-term exposure to pressure and decreased blood circulation. The aim of the study was to examine the effects of gelatin sponge combined with moist wound-healing nursing intervention in the treatment of phase III bedsore. In total, 50 patients with phase III bedsore were included in the present study. The patients were randomly divided into the control (n=25) and observation (n=25) groups. Patients in the control group received conventional nursing, while those in the observation group received gelatin sponge combined with moist wound healing nursing. The effects of the two nursing methods were compared and analyzed. The results showed that the improvement rate of the observation group was significantly higher than that of the control group (P<0.05). The Branden score and area of pressure sore of the observation group were significantly lower than those of the control group (P<0.05). The frequency and time of dressing change and the average cost of hospitalization of the observation group were significantly lower than those of the control group (P<0.001). In conclusion, gelatin sponge combined with moist wound-healing nursing intervention may significantly improve the treatment of phase III bedsore.