The role of psychological distress in the relationship between the severity of pressure injury and pain intensity in hospitalized adults

Body mass index and pressure injuries risk in hospitalized adult patients: A dose-response analysis

BACKGROUND

The association between underweight and pressure injuries (PIs) has been established in several studies. However, there is a lack of well-designed research investigating the connection between overweight and obesity with these injuries.

OBJECTIVE

This meta-analysis aims to investigate the dose-response relationship between body mass index (BMI) and the risk of PIs in adult hospitalized patients.

METHODS

PubMed, Web of Science, and MEDLINE Databases were searched from inception to May 2024. Observational articles with at least three BMI categories were included in the study. BMI was defined as underweight, normal weight, overweight, and morbid obesity for the meta-analysis. The non-linear relationship between BMI and the risk of PIs in hospitalized adults was investigated using restricted cubic spline models. Fractional polynomial modeling was used.

RESULTS

Eleven articles reporting at least 3 categories of BMI met the inclusion criteria, including 31,389 participants. Compared to patients with normal weight, those with underweight, obesity, and morbid obesity exhibited an increased risk of PIs, with odds ratios of 1.70 (95%CI:1.50-1.91), 1.12 (95%CI:1.02-1.24), 1.70 (95%CI:1.13-2.55), respectively. A J-shaped dose-response model was established for the relationship between PI risk and BMI (Pnon-linearity < 0.001, Plinearity = 0.745).

CONCLUSION

The J-shaped dose-response pattern revealed that underweight, obesity and morbid obesity heightened the risk of PIs in hospitalized adults. Lower and higher BMI values may signify an increased risk for PIs, particularly among the elderly with lower BMI, providing valuable guidance for medical staff.

The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta-analysis

BACKGROUND

Numerous interventions for pressure injury prevention have been developed, including care bundles.

OBJECTIVE

To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients.

DATA SOURCES

The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023).

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded.

PARTICIPANTS AND INTERVENTIONS

Bundles with ≥3 components directed towards patients and implemented in ≥2 hospital services were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42023423058.

TWEETABLE ABSTRACT

Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low.

Risk factors predicting hospital-acquired pressure injury in adult patients: An overview of reviews

BACKGROUND

Hospital-acquired pressure injuries remain a significant patient safety threat. Current well-known pressure injury risk assessment tools have many limitations and therefore do not accurately predict the risk of pressure injury development over diverse populations. A contemporary understanding of the risk factors predicting pressure injury in adult hospitalised patients will inform pressure injury prevention and future researchers considering risk assessment tool development may benefit from our summary and synthesis of risk factors.

OBJECTIVE

To summarise and synthesise systematic reviews that identify risk factors for hospital-acquired pressure injury development in adult patients.

DESIGN

An overview of systematic reviews.

METHODS

Cochrane and the Joanna Briggs Institute methodologies guided this overview. The Cochrane library, CINAHL, MEDLINE, and Embase databases were searched for relevant articles published in English from January 2008 to September 2022. Two researchers independently screened articles against the predefined inclusion and exclusion criteria, extracted data and assessed the quality of the included reviews using "a measurement tool to assess systematic reviews" (AMSTAR version 2). Data were categorised using an inductive approach and synthesised according to the recent pressure injury conceptual frameworks.

RESULTS

From 11 eligible reviews, 37 risk factors were categorised inductively into 14 groups of risk factors. From these, six groups were classified into two domains: four to mechanical boundary conditions and two to susceptibility and tolerance of the individual. The remaining eight groups were evident across both domains. Four main risk factors, including diabetes, length of surgery or intensive care unit stay, vasopressor use, and low haemoglobin level were synthesised. The overall quality of the included reviews was low in five studies (45 %) and critically low in six studies (55 %).

CONCLUSIONS

Our findings highlighted the limitations in the methodological quality of the included reviews that may have influenced our results regarding risk factors. Current risk assessment tools and conceptual frameworks do not fully explain the complex and changing interactions amongst risk factors. This may warrant the need for more high-quality research, such as cohort studies, focussing on predicting hospital-acquired pressure injury in adult patients, to reconsider these risk factors we synthesised.

REGISTRATION

This overview was registered with the PROSPERO (CRD42022362218) on 27 September 2022.

Perceived barriers and facilitators to preventing hospital-acquired pressure injury in paediatrics: A qualitative analysis

AIM

This qualitative study aimed to identify nurses' and allied health professionals' perceptions and experiences of providing hospital-acquired pressure injury (HAPI) prevention in a paediatric tertiary hospital in Australia, as well as understand the perceived barriers and facilitators to preventing HAPI.

DESIGN

A qualitative, exploratory study of hospital professionals was undertaken using semi-structured interviews between February 2022 and January 2023.

METHODS

Two frameworks, the Capability, Opportunity and Motivation Model of Behaviour (COM-B) and the Theoretical Domains Framework (TDF), were used to give both theoretical and pragmatic guidance. Participants included 19 nursing and allied health professionals and data analysis was informed by the framework approach.

RESULTS

Analysis revealed nine core themes regarding professionals' beliefs about the barriers and facilitators to HAPI prevention practices across seven TDF domains. Themes included HAPI prevention skills and education, family-centred care, automated feedback and prompts, allocation and access to equipment, everybody's responsibility, prioritizing patients and clinical demands, organizational expectations and support, integrating theory and reality in practice and emotional influence.

CONCLUSION

These findings provide valuable insights into the barriers and facilitators that impact paediatric HAPI prevention and can help identify and implement strategies to enhance evidence-based prevention care and prevent HAPI in paediatric settings.

IMPACT

Overcoming barriers through evidence-based interventions is essential to reduce HAPI cases, improve patient outcomes, and cut healthcare costs. The findings have practical implications, informing policy and practice for improved preventive measures, education, and staffing in paediatric care, ultimately benefiting patient well-being and reducing HAPIs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. The focus of the study is on healthcare professionals and their perspectives and experiences in preventing HAPIs in paediatric patients. Therefore, the involvement of patients or the public was not deemed necessary for achieving the specific research objectives.

Prevalence of Poor Sleep Quality and Associated Factors in Individuals with Rheumatoid Arthritis: A Cross-Sectional Study

Background and Objectives: Poor sleep quality has been frequently observed in individuals with rheumatoid arthritis. In the present study, we analyzed the presence of poor sleep quality in a sample of Mexican individuals with rheumatoid arthritis; then, we compared sociodemographic and clinical characteristics among patients to determine risk factors for poor sleep quality. Materials and Methods: In this cross-sectional study, we included 102 individuals with rheumatoid arthritis from a hospital in Mexico. We evaluated disease activity (DAS28), quality of sleep using the Pittsburgh Sleep Quality Index, and the presence of depression and anxiety with the Hospital Anxiety and Depression Scale. We performed a Chi-square test and a t-test. Then, we performed a logistic regressions model of the associated features in a univariable analysis. Results: Poor sleep quality was observed in 41.75% of the individuals with rheumatoid arthritis. Being married was a proactive factor (OR 0.04, 95% CI 0.1-0.9, p = 0.04), whereas having one's hips affected or presenting with anxiety and depression was associated with poor sleep quality (OR 4.6, 95% CI 1.2-17.69, p = 0.02). After a multivariate analysis, having anxiety (OR 5.0, 95% CI 1.4-17.7, p < 0.01) and depression (OR 9.2, 95% CI 1.0-8.1, p < 0.01) remained associated with a higher risk of having poor sleep quality. Other clinical characteristics among patients were not significantly different. Conclusions: Our results showed that individuals with rheumatoid arthritis who also presented with depression or anxiety had a higher risk of suffering from poor sleep quality. However, more studies with larger samples are necessary to replicate these results in the Mexican population.

Variations in sacral sub-epidermal moisture measurements in hospitalized medical and surgical patients: A longitudinal observational sub-study

BACKGROUND

Pressure injury risk assessment tools have several well-known limitations. As a result, new methods of assessing risk are emerging, including the use of sub-epidermal moisture measurement to detect localized edema.

AIMS

To assess the daily variation in sacral sub-epidermal moisture measurement over five days and establish if age and prophylactic sacral dressing use influenced these measurements.

METHODS

As part of a larger randomized controlled trial of the use of prophylactic sacral dressings, a longitudinal observational substudy was undertaken in hospitalized medical and surgical adult patients at risk of pressure injury. The substudy was conducted in consecutively recruited patients from 20 May 2021 to 9 November 2022. Using the SEM 200 (Bruin Biometrics LLC), daily sacral sub-epidermal measurements for up to five days were completed. Two measurements were generated, the most recent sub-epidermal moisture measurement and, after at least three measurements, a delta value, the difference between the highest and lowest values. The delta measurement was the outcome, with a delta of ≥0.60 considered abnormal, increasing the risk of pressure injury development. A mixed analysis of covariance was undertaken to determine if there was any change in delta measurements over the five days and to determine if age and sacral prophylactic dressing use influenced sub-epidermal moisture delta measurement.

RESULTS

A total of 392 participants were included in this study; 160 (40.8%) patients had completed five consecutive days of sacral sub-epidermal moisture delta measurements. In total, 1324 delta measurements were undertaken across the five study days. In total, 325 of 392 patients (82.9%) had experienced one or more abnormal delta. Furthermore, 191 (48.7%) and 96 (24.5%) of patients experienced abnormal deltas for two or more and three or more consecutive days. There was no statistically significant variation in sacral sub-epidermal moisture delta measurements over time; increasing age and prophylactic dressing use did not influence sub-epidermal moisture deltas over the five days.

CONCLUSION

If only one abnormal delta was used as a trigger, about 83% of patients would have received additional pressure injury prevention strategies. But, if a more nuanced approach to responding to abnormal deltas is taken, between 25 and 50% of patients may receive additional pressure injury prevention, representing a more time and resource efficient approach.

TWEETABLE ABSTRACT

Sub-epidermal moisture delta measurements did not vary over 5 days; increasing age and prophylactic dressing use did not influence these measurements.

Pressure injuries in Australian public hospitals: A cost of illness study

BACKGROUND

Pressure injuries are a leading hospital adverse event, yet they are mostly preventable. Understanding their financial costs will help to appreciate the burden they place on the health system and assist in better planning and management of health expenditures to prevent pressure injuries.

OBJECTIVE

To estimate the cost of pressure injuries in Australian public hospitals in 2020 demonstrating its economic burden in a well-resourced health system.

METHODS

A cost of illness study with a 12-month time horizon was conducted. Resource use for the treatment of pressure injuries and productivity loss due to pressure injuries were derived using a bottom-up approach. Parameters of the cost estimates were obtained from secondary sources and literature syntheses. A simulation with 10,000 draws was used to generate statistical properties of the cost estimates.

RESULTS

Based on a prevalence of 12.9%, the total cost of pressure injuries in Australian public hospitals was $9.11 billion [95% confidence intervals: 9.02, 9.21]. The two largest shares of costs were accounted for by the opportunity cost of excess length of stay of $3.60 billion [3.52, 3.68] and treatment costs of $3.59 billion [3.57, 3.60]. Productivity loss associated with pressure injuries amounts to $493 million [482, 504]. Hospital-acquired pressure injuries account for a total of $5.50 billion [5.44, 5.56], whereas pressure injuries present on admissions costed $3.71 billion [3.70, 3.72]. In terms of severity, Stage 2 pressure injuries contributed the most to total treatment costs, total excessive length of stay, and total loss of healthy life years. Australian society is willing to pay $1.43 billion [1.40, 1.45] to save 6,701 [6,595; 6,807] healthy life years lost by pressure injury.

CONCLUSIONS

Reducing preventable pressure injuries and stopping the progression of Stage 1 pressure injuries will likely result in an immense cost-saving for Australia and will likely have similar benefits for other countries with comparable profiles.

TWEETABLE ABSTRACT

Australian public hospital study provides comprehensive analysis of the cost of pressure injury, including estimates of direct and indirect medical costs, and indirect non-medical costs - such as productivity and quality of life.

Prevention Effects of Chain Management on Pressure Ulcers of Hospitalized Patients

The study focused on the preventive effects of the chain management model on pressure ulcers in the operating room. Sqoop big data collection module is used to collect patient information from various hospital information systems in a distributed manner. The data were from the clinical data center of the Zhongshan Hospital Xiamen University General Hospital, and 268 patients were selected as the research subjects. A chain management model is constructed, concerning the preventive measures, the management of each link, the perioperative pressure ulcer management, and the reporting of pressure ulcers. Then, the two groups were compared for the SAS and SDS scores before and after nursing, the pressure ulcer sites, pressure ulcer reporting rate, pressure ulcer staging, and nursing satisfaction. The results show that it is not that more collection modules will lead to better cluster performance and that the execution delay is caused by MapReduce requiring the JAVA virtual machine, and after reaching a certain point, the increase in the number of tasks will slow down the process, and as data size increases, DataNote has an expanded capability to analyze data. After nursing treatment, the SAS and SDS scores of the two groups of patients were significantly lower than before treatment (P < 0.05). The pressure ulcers were mainly distributed in the forehead, mandible, cheeks, front chest, and knees in the two groups, and the difference between the two groups was statistically significant (P < 0.05). The total satisfaction of the observation group was 93.28%, and the total satisfaction of the control group was 92.54%. The patients' satisfaction with the chain management model was higher than that of conventional nursing.

Pressure injury prevention practices among medical surgical nurses in a tertiary hospital: An observational and chart audit study

Pressure injuries are frequently occurring adverse events in hospitals, negatively impacting patient safety and quality of care. Most pressure injuries are avoidable if effective prevention strategies are used. However, the extent to which various settings influence their use of prevention strategies is unknown. The aim of this study was to describe and compare pressure injury prevention strategies used by medical and surgical nurses in the Chinese context. In this observational study, we used semi-structured observations with chart audits to collect data in two medical and two surgical wards in a tertiary hospital from June to December 2020. Observations were patient-focused; any prevention practices the patient received were recorded, and a chart audit was used to identify documented prevention strategies. The frequency of each prevention strategy was reported, and differences between medical and surgical wards were analysed using independent t-test or χ² test. A total of 577 patients (n = 294, 50.9% medical; n = 283, 49.1% surgical) were observed and their charts audited. Risk assessment was completed on admission for all patients. Repositioning was the most frequently used strategy, with about 84% (n = 486) patients being repositioned regularly. However, skin care, nutritional risk screening and the use of support surfaces were suboptimal. Patient education was not commonly observed but was documented in 75% (n = 433) of audited charts. More medical patients' skin was kept clean and hydrated, but more surgical patients received barrier creams, had a support surface and received more nutrition support and if a prone position was used, they were more likely to be turned after 2 hr and to be repositioned after sitting in a chair for an hour. Prevention strategies were more likely to be documented in surgical patients' charts. Despite pressure injury prevention guideline recommendations provided various prevention strategies for nurses to apply, the observed use of some strategies such as nutrition, skin care and support surfaces was not ideal. Nurses relied heavily on repositioning for pressure injury prevention. Most pressure injury prevention practices need improvement although surgical patients generally received better preventative care. These findings can facilitate clinicians and nurse managers when tailoring future pressure injury prevention work.

Multidimensional Pain Characteristics in Older Adults with Chronic Venous Leg Ulcers

Objective: Pain affects wound healing, treatment, and quality of life because it has significant impacts on physical, psychological, and social well-being. Despite the fact that more than half of chronic venous leg ulcer (CVLU) patients experience mild-to-moderate pain, the multidimensional characteristics of CVLU pain are not well documented. The objective of this study was to describe the multidimensional pain characteristics, including the sensory, affective, cognitive, and behavioral dimensions, of CVLU before debridement. Approach: Participants (N = 40) were recruited from a wound clinic. We conducted a descriptive analysis of clinical data, including pain, wound, and demographic characteristics, collected at the first visit. Results: The mean age of participants was 70.8 ± 9.1 years, 22 (55%) participants were female, and 35 (87.5%) were white. Participants reported mean current pain intensity (2.9 ± 2.7), least (1.2 ± 2.2) and worst (4.8 ± 3.4) pain intensity in 24 h, and tolerable pain level (4.9 ± 2.64) on a 0-10 scale. They described pain as periodic (66.7%, n = 26) with multiple pain quality descriptors (5.4 ± 2.9). Their past pain treatments provided some pain relief (65%, n = 25). For 68% (n = 27), their pain was the same as they expected. Nearly all had a tendency not to tell others about their pain (95%, n = 38). Innovation: This study is the first to describe the multidimensional pain characteristics of patients with CVLU as measured with PAINReportIt. Conclusion: Patients with CVLU reported willingness to tolerate a relatively high level of pain and experience the level of pain they anticipate. Multidimensional pain assessment will assist clinicians to select individualized therapies to manage pain and improve quality of life for these patients.

Metabolomics: Impact of Comorbidities and Inflammation on Sickness Behaviors for Individuals with Chronic Wounds

Significance: Approximately 6.5 million people in the United States suffer from chronic wounds. The chronic wound population is typically older and is characterized by a number of comorbidities associated with inflammation. In addition to experiencing wound-related pain, individuals with chronic wounds commonly experience multiple concurrent psychoneurological symptoms such as fatigue and depression, which delay wound healing. However, these distressing symptoms have been relatively overlooked in this population, although their adverse effects on morbidity are well established in other chronic disease populations. Recent Advances: Inflammation is involved in multiple pathways, which activate brain endothelial and innate immune cells that release proinflammatory cytokines, which produce multiple symptoms known as sickness behaviors. Inflammation-based activation of the kynurenine (KYN) pathway and its metabolites is a mechanism associated with chronic illnesses. Critical Issues: Although putative humoral and neuronal routes have been identified, the specific metabolic variations involved in sickness behaviors in chronic wound patients remain unclear. To improve health outcomes in the chronic wound population, clinicians need to have better understanding of the mechanisms underlying sickness behaviors to provide appropriate treatments. Future Directions: This article presents a synthesis of studies investigating associations between inflammation, metabolic pathways, and sickness behaviors in multiple chronic diseases. The presentation of a theoretical framework proposes a mechanism underlying sickness behaviors in the chronic wound population. By mediating the immune system response, dysregulated metabolites in the KYN pathway may play an important role in sickness behaviors in chronic inflammatory conditions. This framework may guide researchers in developing new treatments to reduce the disease burden in the chronic wound population.

Pain Management in Clinical Practice Research Using Electronic Health Records

BACKGROUND

The use of electronic health record (EHR) systems encourages and facilitates the use of data for the development and surveillance of quality indicators, including pain management.

AIM

to conduct an integrative review on pain management research using data extracted from EHR in order to synthesize and analyze the following elements: pain management (assessments, interventions, and outcomes) and study results with potential clinical implications, data source, clinical sample characteristics, and method description.

DESIGN

An integrative review of the literature was undertaken to identify exemplars of scientific research studies that explore pain management using data from EHR, using Cooper's framework.

RESULTS

Our search of 1,061 records from PubMed, Scopus, and Cinahl was narrowed down to 28 eligible articles to be analyzed.

CONCLUSION

Results of this integrative review will make a critical contribution, assisting others in developing research proposals and sound research methods, as well as providing an overview of such studies over the past 10 years. Through this review it is therefore possible to guide new research on clinical pain management using EHR.

The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines

BACKGROUND

Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations.

OBJECTIVE

To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines.

DESIGN

Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories.

REVIEW METHODS

We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews.

RESULTS

Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline.

CONCLUSIONS

There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies.