Reducing pressure ulcers in patients with prolonged acute mechanical ventilation: a quasi-experimental study

Incidence and Risk Factors for Medical Device-Related Pressure Injury in Hemodynamically Unstable Intensive Care Unit Patients: A Prospective Cohort Study

PURPOSE

The purpose of this study was to determine the incidence and identify potential risk factors for medical device-related pressure injury (MDRPI) in critically ill and hemodynamically unstable adults (patients classified class III or IV on the Therapeutic Intervention Scoring System-28; TISS-28).

DESIGN

Prospective cohort study.

SUBJECTS AND SETTING

The target population was critically ill adults who were using one or more medical devices and categorized as class III or IV on the TISS-28. The study sample comprised 77 participants followed daily until discharge, death, transfer, or lesion development. Data were collected from January to March 2020. The study setting was an intensive care unit with 40 beds in a large hospital in a municipality in the state of Minas Gerais, Brazil.

METHODS

Sociodemographic and pertinent clinical data, pressure injury (PI) risk assessed using the Braden Scale for Pressure Sore Risk, and head-to-toe skin inspections were completed. The incidence rate of MDRPIs was calculated, and survival analyses were completed via the Kaplan-Meier method and Cox regression model.

RESULTS

Forty-nine of 77 participants developed an MDRPI, reflecting an incidence rate of 63.6%. Collectively, 71 MDRPIs occurred in these 49 participants. Univariate analysis indicated significant associations between MDRPI occurrences and level of consciousness ( P = < .001), use of tube holder for ventilation devices ( P = .013), nasal cannula ( P = .034), nasogastric cannula ( P = .034), presence of edema ( P = .001), infection ( P = .007), higher TISS score ( P = .047), and greater number of medical devices ( P = .022). Survival analysis indicated that a high or very high-risk score on the Braden Scale for Pressure Sore Risk ( P = .043) and edema ( P = .030) are risk factors for MDRPI occurrences in this vulnerable population.

CONCLUSIONS

The incidence rate of MDRPIs was 63.6%. The categories with the highest high or very high risk scores on the Braden Scale for Risk of Pressure Pain and Edema emerged as risk factors for MDRPI in this critically ill and vulnerable population.

Relationship between nutritional goals and pressure injuries in critical care patients receiving enteral nutrition

OBJECTIVE

To examine the relationship between pressure injury (PI) development and achievement of nutritional goals (protein and caloric), as well as consider the clinical conditions, hospitalisation factors, and risk assessment for PI development in patients who are critically ill and receiving enteral nutrition (EN) in the intensive care unit (ICU).

METHOD

An observational cohort study was conducted in the ICU of the University Hospital in São Paulo, Brazil. Inclusion criteria were as follows: age ≥18 years; length of ICU stay ≥24 hours; without PI at ICU admission; and receiving EN exclusively during ICU stay. The development of PI was considered the dependent variable. The Chi-squared test was applied to compare categorical variables, and the Mann-Whitney U test was used to compare continuous variables between groups of patients with and without a PI. The analysis of the achievement of nutritional goals was performed using Fisher's exact test. A significance level of 5% (p-value<0.05) and a confidence interval (CI) of 95% was adopted in all statistical tests.

RESULTS

A total of 181 patients met the inclusion criteria, of whom 102 (56.4%) were male and 79 (43.6%) were female. Mean age was 55.1 years, and mean length of ICU stay was 17.5 days. PI development was associated with not achieving nutritional goals. There was a higher percentage (65.3%) of patients without a PI when both protein and caloric goals were achieved. In contrast, 45.6% of patients developed a PI when the goals were not achieved. The mean days for sedation, vasoactive drugs and mechanical ventilation were all significantly higher in patients who developed a PI (p<0.001).

CONCLUSION

There was a significant association between patients developing a PI and deficits in caloric and protein intake. Patients who did not develop PIs had a greater calorie and protein intake compared with those who developed a PI.

Family-centred empowerment using telenursing on pressure injury incidence in post-discharge stroke patients

OBJECTIVE

The aim of this study was to evaluate the effect of a family-centred empowerment intervention on the incidence, stage and status of pressure injury (PI) in patients diagnosed with stroke during the post-discharge period with a telenursing approach.

METHOD

This randomised controlled clinical trial (RCT) was conducted with patients admitted to Ghaem Hospital in Mashhad and who were diagnosed with stroke. Patients were randomly assigned to one of two equal-sized groups: intervention and control. Family education and follow-up of the intervention group was performed using WhatsApp messenger for one month. Caregivers of patients in the control group received the routine training programme. The incidence, stage and status of PIs of both groups were measured at the beginning and at one month later using the Braden Scale, the EPUAP/NPUAP Classification System, and the Pressure Ulcer Scale for Healing (PUSH).

RESULTS

A total of 60 patients took part in the RCT (30 patients allocated to each group). The incidence of PI in the control group was significantly higher than in the intervention group (p<0.001). The results showed significantly lower stages of PI in the intervention group than in the control group (p<0.001 and p<0.05 for univariable and multivariable models, respectively). The results showed a significantly lower PUSH score in the intervention group than in the control group (p<0.001 and p<0.05 for univariable and multivariable models, respectively).

CONCLUSION

The findings of this RCT show that the empowerment and training of caregivers of patients diagnosed with stroke after discharge using telenursing can reduce the incidence and severity of PIs and improve their status in these patients.

Family participation in essential care activities in adult intensive care units: An integrative review of interventions and outcomes

AIMS AND OBJECTIVES

To systematically review interventions and outcomes regarding family participation in essential care in adult intensive care units.

BACKGROUND

Patients and relatives may benefit from family participation in essential care activities.

DESIGN

An integrative literature review.

METHODS

The following databases were systematically searched from inception to January 25, 2021: PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science and reference lists of included articles. Studies were included when reporting on family participation in essential care activities in intensive care including interventions and outcomes. Quality of the studies was assessed with the Kmet Standard Quality Assessment Criteria. Interventions were assessed, using the TIDieR framework. Data were extracted and synthesised narratively.

RESULTS

A total of 6698 records were screened, and 322 full-text studies were assessed. Seven studies were included, describing an intervention to support family participation. Four studies had a pretest-posttest design, two were pilot feasibility studies and one was observational. The quality of the studies was poor to good, with Kmet-scores: 0.50-0.86 (possible score: 0-1, 1 being the highest). Five studies offered various essential care activities. One study provided sufficient intervention detail. Outcome measures among relatives varied from mental health symptoms to satisfaction, supportiveness, comfort level and experience. Two studies measured patient outcomes: delirium and pressure ulcers. Among ICU healthcare providers, perception, comfort level and experience were assessed. Since outcome measures varied, only narrative synthesis was possible. Family participation is associated with a reduction of anxiety and PTSD symptoms.

CONCLUSION

Intervention descriptions of family participation in essential care activities are generally inadequate and do not allow comparison and replication. Participation of relatives was associated with a significant reduction in mental health symptoms. Other outcome measures varied, therefore, the use of additional outcome measures with validated measurement instruments should be considered.

RELEVANCE TO CLINICAL PRACTICE

The review contributed further insight into interventions aiming at family participation in essential care activities in the intensive care unit and their outcomes.

NO PATIENT OR PUBLIC CONTRIBUTION

Neither patients nor public were involved.

A Multicenter Assessment of Nurses' Knowledge Regarding Pressure Ulcer Prevention in Intensive Care Units Utilizing the PUKAT 2.0

Introduction

Pressure ulcer (PU) care is pivotal in the practice of nurses working in intensive care units (ICUs). Therefore, nurses must possess adequate knowledge about the potential risks leading to the development of PUs, as well as managing complications that worsen patient conditions.

Objective

To evaluate the level of knowledge of ICU nurses concerning PU prevention in tertiary hospitals in Saudi Arabia.

Methods

In this cross-sectional study, the researchers recruited 320 ICU nurses from four tertiary hospitals using convenience sampling. Nurses' knowledge regarding PU prevention was assessed using the revised and updated version of the Pressure Ulcer Knowledge Assessment Tool (PUKAT) 2.0. Data were collected between May and June 2022. The CROSS checklist was observed for reporting.

Results

The mean scores of nurses' level of knowledge regarding PU prevention according to the themes of the revised and updated version of the PUKAT 2.0 were as follows-etiology: 62.81  ±  23.77; classification and observation: 50.86  ±  23.28; risk assessment: 31.19  ±  24.26; nutritious diet: 46.04  ±  25.96; prevention: 22.36  ±  12.41; and specific patient groups: 14.84  ±  22.88. Furthermore, the score for nurses' overall level of knowledge of PU prevention was 39.55  ±  8.84 out of 100, interpreted as low based on the 60% cutoff; the minimum knowledge score was 0. Notably, knowledge of PU etiology, classification, observation, and specific patient groups differed based on the hospital of affiliation. Interestingly, gender was the only demographic characteristic based on which nurses' knowledge regarding specific patient groups differed.

Conclusion

This study identified insufficient knowledge among ICU nurses regarding PU prevention, which can lead to complications among patients. Simulation scenarios related to PU prevention and management will be an effective way to help nurses gain appropriate knowledge that can be applied in clinical practice.

Neuromuscular blocking agents and opioids are major risk factors for developing pressure injuries in patients in the intensive care unit

BACKGROUND/AIMS

Patients in the intensive care unit (ICU) are at high risk for developing pressure injuries, which can cause severe complications and even increase the mortality risk. Therefore, prevention of pressure injuries is most important. In this study, we investigated the risk factors of pressure injury development in patients admitted to the ICU.

METHODS

We retrospectively analyzed patients ages &gt; 18 years admitted to the medical ICU in a tertiary hospital between January and December 2019. We collected patient baseline characteristics, medications received, mechanical ventilation or hemodialysis use, laboratory findings, and date of pressure injury onset and characteristics.

RESULTS

We analyzed 666 patients who did not have pressure injuries at ICU admission. Pressure injuries developed in 102 patients (15%). The risk of pressure injury development increased as the administration days for neuromuscular blocking agents (NMBAs; odds ratio [OR], 1.138; p = 0.019) and opioids (OR, 1.084; p = 0.028) increased, and if the patient had problem with friction and shear (OR, 2.203; p = 0.011).

CONCLUSION

The prolonged use of NMBAs and opioids can increase the risk of pressure injury development. Because these medications are associated with immobilization, using both should be minimized and patient early mobilization should be promoted. Among the Braden subscales, "friction and shear" was associated with the development of pressure injuries in ICU patients.

Family participation in essential care activities: Needs, perceptions, preferences, and capacities of intensive care unit patients, relatives, and healthcare providers—An integrative review

BACKGROUND

Family participation in essential care activities may benefit both patients and relatives.

OBJECTIVES

In this integrative review, we aimed to identify needs, perceptions, preferences, and capacities regarding family participation in essential care in intensive care units (ICUs) from the patient's, relatives', and ICU healthcare providers' perspective.

REVIEW METHOD USED

An integrative review method was used.

DATA SOURCES

PubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science, and reference lists of included articles were searched, from inception to January 25, 2021.

REVIEW METHODS

We included studies on family participation in essential care activities during ICU stay which reported associated needs, perceptions, preferences and capacities. Quality assessment was performed with the Kmet Standard Quality Assessment Criteria developed for evaluating primary research papers in a variety of fields, and an extensive qualitative thematic analysis was performed on the results.

RESULTS

Twenty-seven studies were included. Quality scores varied from 0.45 to 0.95 (range: 0-1). Patients' needs, perceptions, preferences, and capacities are largely unknown. Identified themes on needs and perceptions were relatives' desire to help the patient, a mostly positive attitude among all involved, stress regarding patient safety, perceived beneficial effects, relatives feeling in control-ICU healthcare providers' concerns about loss of control. Preferences for potential essential care activities vary. Relatives want an invitation and support from ICU healthcare providers. Themes regarding capacities were knowledge, skills, education and training, and organisational conditions.

CONCLUSIONS

Implementation of family participation in essential care requires education and training of relatives and ICU healthcare providers to address safety and quality of care concerns, though most studies lack further specification.

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.

Análise retrospectiva da aplicação da escala de Braden Q em terapia intensiva pediátrica

Objetivo: caracterizar o perfil dos pacientes que desenvolveram lesão por pressão e analisar os escores retrospectivos obtidos na aplicação da Escala de Braden Q em terapia intensiva pediátrica. Método: estudo de coorte retrospectivo com análise de dados secundários de 34 prontuários eletrônicos de pacientes internados em terapia intensiva pediátrica. Resultados: da análise dos escores obtidos com aplicação da Escala de Braden Q, foram identificados seis registros de lesão por pressão; a média de idade foi de 8,1 anos; 66,6% do sexo masculino; média de 41 dias de internação; principais diagnósticos estão relacionados a doenças do sistema respiratório, cardíaco e neurológico; todos utilizaram suporte de ventilação mecânica invasiva e apresentaram prescrição de jejum e uso de sonda nasogástrica. Conclusão: o perfil clínico está correlacionado ao sexo masculino, à maior frequência de doenças respiratórias com necessidade de ventilação mecânica, ao uso de drogas vasoativas, vasopressoras e sedativas, e à sonda como via de administração de dieta. Todos apresentaram escores de alto risco para desenvolvimento de lesão por pressão.

Retrospective analysis of the application of the Braden Q scale in pediatric intensive care

Objective: to characterize the profile of patients who developed pressure injuries and to analyze the retrospective scores obtained in the application of the Braden Q Scale in pediatric intensive care. Method: retrospective cohort study with analysis of secondary data from 34 electronic medical records of patients admitted to pediatric intensive care. Results: from the analysis of the scores obtained with the application of the Braden Q Scale, six records of pressure injuries were identified; the average age was 8.1 years; 66.6% were male; average of 41 days of hospitalization; main diagnoses are related to diseases of the respiratory, cardiac and neurological systems; all used invasive mechanical ventilation support and had a fasting prescription and use of a nasogastric tube. Conclusion: the clinical profile is correlated with the male gender, the higher frequency of respiratory diseases requiring mechanical ventilation, the use of vasoactive, vasopressor and sedative drugs, and the tube as a route of dietary administration. All of them had high risk scores for developing pressure injuries.

Impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit: A scoping review

Background

The use of social media in healthcare continues to evolve. The purpose of this scoping review was to summarize existing research on the impact of social media interventions and tools among informal caregivers of critically ill patients after patient admission to the intensive care unit (ICU).

Methods

This review followed established scoping review methods, including an extensive a priori-defined search strategy implemented in the MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials databases to July 10, 2020. Primary research studies reporting on the use of social media by informal caregivers for critically ill patients were included.

Results

We identified 400 unique citations and thirty-one studies met the inclusion criteria. Nine were interventional trials–four randomized controlled trials (RCTs)–and a majority (n = 14) were conducted (i.e., data collected) between 2013 to 2015. Communication platforms (e.g., Text Messaging, Web Camera) were the most commonly used social media tool (n = 17), followed by social networking sites (e.g., Facebook, Instagram) (n = 6), and content communities (e.g., YouTube, SlideShare) (n = 5). Nine studies’ primary objective was caregiver satisfaction, followed by self-care (n = 6), and health literacy (n = 5). Nearly every study reported an outcome on usage feasibility (e.g., user attitudes, preferences, demographics) (n = 30), and twenty-three studies reported an outcome related to patient and caregiver satisfaction. Among the studies that assessed statistical significance (n = 18), 12 reported statistically significant positive effects of social media use. Overall, 16 of the 31 studies reported positive conclusions (e.g., increased knowledge, satisfaction, involvement) regarding the use of social media among informal caregivers for critically ill patients.

Conclusions

Social media has potential benefits for caregivers of the critically ill. More robust and clinically relevant studies are required to identify effective social media strategies used among caregivers for the critically ill.

Effectiveness on hospital-acquired pressure ulcers prevention: a systematic review

The effective approach on pressure ulcer (PU) prevention regarding patient safety in the hospital context was evaluated. Studies were identified from searches in EBSCO host, PubMed, and WebofScience databases from 2009 up to December 2018. Studies were selected if they were published in English, French, Portuguese, or Spanish; incidence of PUs was the primary outcome; participants were adults (≥18 years) admitted in hospital wards and/or units. The review included 26 studies. Studies related to prophylactic dressings applied in the sacrum, trochanters, and/or heels, education for health care professionals, and preventive skin care and system reminders on-screen inpatient care plan were effective in decreasing PUs. Most of the studies related to multiple intervention programmes were effective in decreasing PU occurrence. Single interventions, namely support surfaces and repositioning, were not always effective in preventing PUs. Repositioning only was effective when supported by technological pressure-mapping feedback or by a patient positioning system. Risk-assessment tools are not effective in preventing PUs. PUs in the hospital context are still a worldwide issue related to patient safety. Multiple intervention programmes were more effective in decreasing PU occurrence than single interventions in isolation. Single interventions (prophylactic dressings, support surfaces, repositioning, preventive skin care, system reminders, and education for health care professionals) were effective in decreasing PUs, which was always in compliance with other preventive measures. These results provide an overview of effective approaches that should be considered when establishing evidence-based guidelines to hospital health care professionals and administrators for clinical practice effective in preventing PUs.

Reducing Pressure Injuries in a Pediatric Cardiac Care Unit: A Quality Improvement Project

The purpose of this quality improvement project was to develop an evidence-based protocol designed for pressure injury prevention for neonates and children in a pediatric cardiac care unit located in the Midwestern United States. The ultimate goal of the project was dissemination across all pediatric critical care and acute care inpatient arenas, but the focus of this initial iteration was neonates and children requiring cardiac surgery, extracorporeal support in the form of extracorporeal membranous oxygenation and ventricular assist devices in the cardiac care unit, or cardiac transplantation. A protocol based upon the National Pressure Ulcer Advisory Panel guidelines was developed and implemented in the pediatric cardiac care unit. Pediatric patients were monitored for pressure injury development for 6 months following protocol implementation. During the 40-month preintervention period, 60 hospital-acquired pressure injuries (HAPIs) were observed, 13 of which higher than stage 3. In the 6-month postintervention period, we observed zero HAPI greater than stage 2. We found that development and use of a standardized pressure injury prevention protocol reduced the incidence, prevalence, and severity of HAPIs among patients in our pediatric cardiac care unit.

Understanding the Hawthorne effect in wound research-A scoping review

The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.