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

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.

Pressure ulcers during the COVID-19 pandemic in intensive care:A multicenter cohort study

AIM

The objective of the present study is twofold: to describe the prevalence and incidence of pressure ulcers (PUs) among ICU patients during the COVID-19 pandemic, and to identify the risk factors associated with the development of PUs in this cohort of ICU patients.

MATERIALS AND METHODS

Retrospective cohort study of adult critical care patients admitted in two general ICUs of two different countries (Sweden and Portugal) between March 1st, 2020, and April 30th, 2021, through the analysis of the electronic health record database. The prevalence and incidence were calculated, and a multivariate logistic-regression model was used to calculate odds ratios (ORs), of possible risk factors of PU development.

RESULTS

The sample consisted of 1717 patients. The overall prevalence of PU was 15.3 %, and the incidence of ICU-acquired PUs was 14.1 %. Most of the pressure ulcers documented in this study were at the anterior part of the body (45.35 %) and regarding classification, Category 2 (38.40 %) and Category 3 (22.71 %) pressure ulcers together accounted for over fifty percent of the cases recorded. In the multivariate logistic regression model for PU, age, having COVID-19 (OR = 1.58, 95 % CI: 1.20-2.09), use of mechanical ventilation (OR = 1.49, 95 % CI: 1.13 = 1.97), use of vasopressors (OR = 1.31, 95 % CI: 1.00-1.70), having a Braden risk score ≤16 at admission (OR = 1.63; 95 % CI: 1.04-2.56), and length of stay (LOS) (OR = 1.43, 95 % CI 1.03-2.00 if LOS 90-260 h, OR = 2.34, 95 % CI: 1.63-3.35 if LOS >260 h) were associated with the likelihood of developing an ICU-acquired PUs.

CONCLUSION

When adjusted for covariates patients with COVID-19 had a higher risk for PU development during the ICU stay compared to patients without COVID-19. Health care personnel in ICU may consider incorporating COVID-19, age, use of mechanical ventilation, vasopressors and estimated LOS in addition to a comprehensive risk assessment including both a risk score and clinical assessment.

Validity and reliability of the Waterlow scale for assessing pressure injury risk in critical adult patients: A multi-centre cohort study

AIM

To evaluate the predictive validity and reliability of the Waterlow scale in critically adult hospitalised patients.

DESIGN

A multi-centre cohort study.

METHODS

This study was conducted in 72 intensive care units (ICUs) in 38 tertiary hospitals in Gansu Province, China. All adults admitted to the ICU for greater than or equal to 24 h without pressure injury (PI) on admission were screened by the Waterlow scale on admission, during ICU stay and ICU discharge from April 2021 to February 2023. Receiver operating characteristic (ROC) curves were used to determine a potential cut-off value for critical adult hospitalised patients. Cut-off values were then determined using Youden's index, and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated based on these cut-off values. Test-retest reliability was used to evaluate inter-rater reliability.

RESULTS

A total of 5874 critical patients on admission were included, and 5125 of them were assessed regularly. The area under curve (AUC) was 0.623 (95% CI, 0.574-0.690), with a cut-off score of 19 showing the best balance among sensitivity of 62.7%, specificity of 57.4%, positive predictive value of 2.07% and negative predictive value of 99.08%. The test-retest reliability between the first assessment and the regular assessment was 0.447.

CONCLUSIONS

The Waterlow scale shows insufficient predictive validity and reliability in discriminating critical adults at risk of PI development. To further modify the items of the Waterlow scale, exploring specific risk factors for PI in the ICU and clarifying their impact degree was necessary. Risk predictive models or better tools are inevitable in the future.

PATIENT OR PUBLIC CONTRIBUTION

Patients or family members supported nurses with PI risk assessment, skin examination and other activities during the inquiry.

The theory and practice of pressure ulcer/injury risk assessment: a critical discussion

Pressure ulcer/injury (PU) risk assessment is widely considered an essential component in clinical practice. It is a complex and broad concept that includes different approaches, such as clinical judgement, using standardised risk assessment instruments, skin assessments, or using devices to measure skin or tissue properties. A distinction between PU risk assessment and early detection is important. PU risk measures the individual's susceptibility to developing a PU under a specific exposure (primary prevention), and early detection includes the assessment of early (sub)clinical signs and symptoms to prevent progression and to support healing (secondary prevention). PU risk is measured using prognostic/risk factors or prognostic models. Every risk estimate is a probability statement containing varying degrees of uncertainty. It therefore follows that every clinical decision based on risk estimates also contains uncertainty. PU risk assessment and prevention is a complex intervention, where delivery contains several interacting components. There is a huge body of evidence indicating that risk assessment and its outcomes, the selection of preventive interventions and PU incidence are not well connected. Methods for prognostic model development and testing in PU risk research must be improved and follow state-of-the-art methodological standards. Despite these challenges, we do have substantial knowledge about PU risk factors that helps us to make better clinical decisions. An important next step in the development of PU risk prediction might be the combination of clinical and other predictors for more individualised care. Any prognostic test or procedure must lead to better prevention at an acceptable cost.

Safety and usability of proning pillows in intensive care: A scoping review

OBJECTIVES

Proning is an established technique for the care of intubated patients with severe respiratory failure. Positioning devices used to support the head and body of patients placed in the prone position are often associated with the formation of pressure injuries. Despite robust literature on the prevention and monitoring of pressure injuries, little is described about the role of proning pillows on pressure injuries. The objective of this review is to understand the extent of evidence pertaining to the safety and usability of different types of proning pillows in the intensive care setting.

REVIEW METHOD

A scoping review of the literature was completed using predefined search terms in three databases and identified 296 articles. An additional 26 were included from reference lists. Twenty studies are included in the analysis; most were published in the past 3 years, with >50% in surgical settings.

DATA SOURCES

Three databases were searched: PubMed, Scopus, and EMBASE.

REVIEW METHODS

The review followed the PRISMA Extension for Scoping Reviews, and data were reviewed using Covidence.

RESULTS

The most prevalent proning pillow is a standard, noncontoured foam head positioner. It is responsible for the majority of facial pressure injuries in all settings of care. Memory foam pillows and helmet-based systems offer improved surface pressure distribution, although their usability in the intensive care setting remains poorly studied. Inflatable air-cell-based devices present an alternative, but the lack of supporting research and the costs may explain their poor uptake. Several articles proposed the use of pressure sensor systems to evaluate devices. We propose a set of ergonomic parametres to consider when choosing or designing a positioning device for proned patients.

CONCLUSION

The evidence pertaining to the safety and usability of proning pillows in the intensive care setting is scarce, which provides opportunities for future research to improve the efficacy in the prevention of pressure injuries and the user experience.

Developing the Baptist Health Injury Risk Assessment Phase 1: Exploring Risk Factors

OBJECTIVES

The aim of this study was to explore risk factors for developing hospital-acquired pressure injuries (HAPIs) among critically ill adult inpatients.

BACKGROUND

Hospital-acquired pressure injuries remain a priority quality focus for Magnet ® organizations. Recent studies cite medical devices as a primary cause, yet published risk assessments lack inclusion of those threats.

METHODS

Nurses at a 434-bed, 4-time Magnet ® -designated hospital led a retrospective study acros 9 American Nurses Credentialing Center-designated facilities. Using a chart review tool, data were collected within 48 hours of a confirmed HAPI.

RESULTS

Of 207 HAPIs reported, 54% (n = 113) involved deep tissue pressure injuries and 50.2% (n = 104) involved 19 medical devices. Individuals with a HAPI also used 1 or more of 7 distinct types of mobility-limiting medical equipment.

CONCLUSIONS

Study findings support the development of a critical care risk assessment with inclusion of a medical device and mobility-limiting medical equipment as risk factors. A secondary study is underway for specificity and sensitivity testing of this assessment.

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.