What makes a good head positioner for preventing occipital pressure ulcers.
Katzengold Rona,Gefen Amit
International wound journal
Patients who are stationary endure prolonged soft tissue distortions and deformations at contact areas between their body and the support surface, which may lead to the onset of pressure ulcers (PUs) over time. A novel technology for patient positioning employs innovation in materials science, specifically viscoelastic materials with shape memory properties that compose the Z-Flo™ head positioner (Mölnlycke Health Care, Gothenburg, Sweden). Head positioners are generally known to reduce the occurrence of PUs in scalp tissues and the ears, but quantitative assessments of their biomechanical efficacy are missing in the literature. To determine potential differences in mechanical loads formed in the soft tissues of the back of the head while in contact with 2 head positioner types, Z-Flo vs flat medical foam, we developed 2 comparable finite element model configurations, both including the same 3-dimensional adult head. For both model variants, stresses in skin and fat peaked at the occiput. The skin at the back of the resting head is subjected to greater stress values with respect to fat; however, the Z-Flo positioner reduced the exposure of both skin and fat tissues to elevated stresses considerably (by a factor of 3) compared to the medical foam support. We found the Z-Flo device effective in reducing tissue loads at the surface of the head as well as internally in scalp tissues, with a particular strength in reducing internal tissue shear. The Z-Flo device achieves this protective quality through highly effective immersion and envelopment of the back of the head, generated in the process of manual moulding of the device in preparation for use. Additional protection is achieved through the viscoelastic response of the filling material of this positioner, which relaxes promptly and considerably under the weight of the head (by more than 2-fold within approximately 1 s) as opposed to the elastic recoil of the foam that pushes back on scalp tissues.
10.1111/iwj.12857
Evaluating pressure redistribution surfaces for the occiput.
Journal of wound care
OBJECTIVE:Patients hospitalised in the Burn Intensive Care Unit are at increased risk of pressure ulcers (PU; also known as pressure injuries). While effective methods exist to offload pressure from other areas, offloading the head is difficult, especially with facial or head burns. An increase in occipital PUs prompted a review of practices for offloading the head in the Burn Intensive Care Unit. METHOD:A multidisciplinary team (MDT) of physicians, occupational therapists and nurses evaluated several devices used to prevent occipital PUs using a pressure mapping device. Pressure was measured using the SensorEdge Measure X device. The pressure mapping device provides a real-time graphic representation of pressure to the body area studied, in this case the occiput. In addition, the SensorEdge allows for numeric data to be exported to Excel format. RESULTS:Our data showed that the occipital pressure was observed in our health volunteer using a fluidised gel positioner using pressure mapping. As a result of this we stopped using other pillows and went to exclusive use of the fluidised gel positioner. Reimplementation and consistent use of a fluidised gel positioner resulted in decreasing occipital PUs from nine to zero. CONCLUSION:The use of a fluidised gel positioner should be considered in other critical care environments to reduce the prevalence of hospital acquired occipital PUs.
10.12968/jowc.2019.28.Sup9.S38
A Tracheostomy Support Device to Reduce Tracheostomy-Related Pressure Injury.
Respiratory care
BACKGROUND:Tracheostomies provide many advantages for the care of patients who are critically ill but may also result in complications, including tracheostomy-related pressure injuries. Research efforts into the prevention of these pressure injuries has resulted in specialized clinical care teams and pathways. These solutions are expensive and labor intensive, and fail to target the root cause of these injuries; namely, pressure at the device-skin interface. Here we measure that pressure directly and introduce a medical device, the tracheostomy support system, to reduce it. METHODS:This was a cross-sectional study of 21 subjects in the ICU, each with a tracheostomy tube connected to a ventilator. A force-sensing resistor was used to measure baseline pressures at the device-skin interface along the inferior flange. This pressure was then measured again with the use of the tracheostomy support system in the inactive and active states. Resultant pressures and demographics were compared. RESULTS:Fifteen male and 6 female subjects, with an average age of 47 ± 14 (mean ± SD) years, were included in this study. Average pressures at the tracheostomy-skin interface at baseline in these 21 ICU subjects were 273 ± 115 (mean ± SD) mm Hg. Average pressures were reduced by 59% (median 62%, maximum 98%) with the active tracheostomy support system to 115 ± 83 mm Hg ( < .001). All the subjects tolerated the tracheostomy support system without issue. CONCLUSIONS:Despite best clinical practice, pressure at the tracheostomy-skin interface can remain quite high. Here we provide measures of this pressure directly and show that a tracheostomy support system can be effective at minimizing that pressure.
10.4187/respcare.11160
Protocol for the Development of the Fourth Edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline Using GRADE Methods.
Advances in skin & wound care
ABSTRACT:The National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance are commencing a new (fourth) edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline . The fourth edition of the International Pressure Injury (PI) Guideline will be developed using GRADE methods to ensure a rigorous process consistent with evolving international standards. Clinical questions will address prevention and treatment of PIs, identification of individuals at risk of PIs, assessment of skin and tissues, and PI assessment. Implementation considerations supporting application of the guidance in clinical practice will be developed. The guideline development process will be overseen by a guideline governance group and methodologist; the guideline development team will include health professionals, educators, researchers, individuals with or at risk of PIs, and informal carers.This article presents the project structure and processes to be used to undertake a systematic literature search, appraise risk of bias of the evidence, and aggregate research findings. The methods detail how certainty of evidence will be evaluated; presentation of relative benefits, risks, feasibility, acceptability, and resource requirements; and how recommendations will be made and graded. The methods outline transparent processes of development that combine scientific research with best clinical practice. Strong involvement from health professionals, educators, individuals with PIs, and informal carers will enhance the guideline's relevance and facilitate uptake. This update builds on previous editions to ensure consistency and comparability, with methodology changes improving the guideline's quality and clarity.
10.1097/ASW.0000000000000079
Inter-rater reliability of the Reaper Oral Mucosa Pressure Injury Scale (ROMPIS): A novel scale for the assessment of the severity of pressure injuries to the mouth and oral mucosa.
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses
BACKGROUND:Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth. OBJECTIVES:This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa. METHODS:The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha (α). RESULTS:Among ICU nurses (n=52), IRR of the ROMPIS was α=0.307; improving to α=0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care (n=8), IRR was α=0.306; or α=0.443 excluding responses indicating that wounds were unstageable. CONCLUSIONS:An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.
10.1016/j.aucc.2016.06.003
Fluidized Positioner to Prevent Occipital Pressure Injury: A Quality Improvement Project.
Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society
PURPOSE:The purpose of this quality improvement project was to determine if head immobilization, pressure redistribution for the occiput, and offloading of pressure from craniotomy incisions could be improved by utilizing fluidized positioners instead of pillows previously used as the standard of care. The second purpose was to determine cost savings for the organization. PARTICIPANTS AND SETTING:Eight patients with head trauma and craniotomy in a surgical intensive care unit (SICU) and cardiovascular intensive care unit (CVICU) from a level 1 trauma center in the Southeast region of the United States participated over a 6-month period. APPROACH:The project comprised educating staff including nurses, nursing assistants, supervisors, and care managers, and implementation of the head positioner from July 2018 to December 2018. Staff from the SICU and CVICU, a step-down unit, and a neurological ICU were also educated on the fluidized positioner, because patients were transferred to these units when stable. All patients who underwent craniotomy surgery were placed on the fluidized positioner postoperatively until immobilization and offloading were no longer required. OUTCOME:During the initial 6-month evaluation period, no new pressure injuries or incisional trauma occurred in the 8 patients. The economic impact to treat one hospital-acquired unstageable pressure injury was estimated at $78,722. Because no new occipital pressure injuries occurred in the 8 patients placed on the fluidized head positioner, the hospital potentially saved $629,776. IMPLICATION FOR PRACTICE:Findings from the project suggest that implementation of a fluidized positioner can redistribute pressure to the occiput, offload craniotomy incision sites, and prevent pressure injuries.
10.1097/WON.0000000000000847
Pressure injury prevalence in Australian intensive care units: A secondary analysis.
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses
BACKGROUND:Pressure injuries (PIs) are an enduring problem for patients in the intensive care unit (ICU) because of their vulnerability and numerous risk factors. METHOD:This study reports Australian data as a subset of data from an international 1-day point prevalence study of ICU-acquired PI in adult patients. Patients aged 18 years or older and admitted to the ICU on the study day were included. The outcome measure was the identification of a PI by direct visual skin assessment on the study day. Data collected included demographic data and clinical risk factors, PI location and stage, and PI prevention strategies used. Descriptive statistics were used to describe PI characteristics, and odds ratios (ORs) were used to identify factors associated with the development of a PI. RESULTS:Data were collected from 288 patients from 16 Australian ICUs. ICU-acquired PI prevalence was 9.7%, with 40 PIs identified on 28 patients. Most PIs were of stage 1 and stage 2 (26/40, 65.0%). Half of the ICU-acquired PIs were found on the head and face. The odds of developing an ICU-acquired PI increased significantly with renal replacement therapy (OR: 4.25, 95% confidence interval [CI]: 1.49-12.11), impaired mobility (OR: 3.13, 95% CI: 1.08-9.12), fastest respiratory rate (OR: 1.05 [per breath per minute], 95% CI: 1.00-1.10), longer stay in the ICU (OR: 1.04 [per day], 95% CI: 1.01-1.06), and mechanical ventilation on admission (OR: 0.36, CI: 0.14-0.91). CONCLUSION:This study found that Australian ICU-acquired PI prevalence was 9.7% and these PIs were associated with many risk factors. Targeted PI prevention strategies should be incorporated into routine prevention approaches to reduce the burden of PIs in the Australian adult ICU patient population.
10.1016/j.aucc.2021.10.009
Explainable Artificial Intelligence for Early Prediction of Pressure Injury Risk.
American journal of critical care : an official publication, American Association of Critical-Care Nurses
BACKGROUND:Hospital-acquired pressure injuries (HAPIs) have a major impact on patient outcomes in intensive care units (ICUs). Effective prevention relies on early and accurate risk assessment. Traditional risk-assessment tools, such as the Braden Scale, often fail to capture ICU-specific factors, limiting their predictive accuracy. Although artificial intelligence models offer improved accuracy, their "black box" nature poses a barrier to clinical adoption. OBJECTIVE:To develop an artificial intelligence-based HAPI risk-assessment model enhanced with an explainable artificial intelligence dashboard to improve interpretability at both the global and individual patient levels. METHODS:An explainable artificial intelligence approach was used to analyze ICU patient data from the Medical Information Mart for Intensive Care. Predictor variables were restricted to the first 48 hours after ICU admission. Various machine-learning algorithms were evaluated, culminating in an ensemble "super learner" model. The model's performance was quantified using the area under the receiver operating characteristic curve through 5-fold cross-validation. An explainer dashboard was developed (using synthetic data for patient privacy), featuring interactive visualizations for in-depth model interpretation at the global and local levels. RESULTS:The final sample comprised 28 395 patients with a 4.9% incidence of HAPIs. The ensemble super learner model performed well (area under curve = 0.80). The explainer dashboard provided global and patient-level interactive visualizations of model predictions, showing each variable's influence on the risk-assessment outcome. CONCLUSION:The model and its dashboard provide clinicians with a transparent, interpretable artificial intelligence-based risk-assessment system for HAPIs that may enable more effective and timely preventive interventions.
10.4037/ajcc2024856
Pressure injury can occur in patients undergoing prolonged head and neck surgery.
Wright Kathleen M,Van Netten Yvonne,Dorrington Carol A,Hoffman Gary R
Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons
PURPOSE:The aim of this study was to estimate the frequency of and identify the risks factors associated with the development of pressure injuries (PIs) in a sample of patients who underwent operative treatment of a head and neck malignancy. MATERIALS AND METHODS:The sample was composed of patients admitted under the care of the Combined Head and Neck Service, John Hunter Hospital from 2010 to 2012 and whose operation was a minimum of 5 hours duration. The predictor variables included a range of demographic, comorbidity, and operative factors. The outcome variable was the development of a PI. A multivariate logistic regression model was conducted to assess the association between predictor variables and the outcome variable (PI). RESULTS:Eighty-eight patients (62 male and 26 female) were included in the study. PIs were identified in 13 patients (14%). These injuries were typically located over bony prominences, in keeping with findings identified in the relevant literature. Specifically, an increased risk of PI was seen with decreasing patient age (54.5 ± 11.6 yr for PI vs 63.1 + 10.8 yr for no PI; P = .01) and increasing operative duration (729 ± 79 minutes for PI vs 625 ± 158 minutes for no PI; P = .02). CONCLUSIONS:PIs can occur in patients who undergo prolonged head and neck resective and reconstructive surgery. In particular, decreasing age and increasing operative duration were shown to be statistically significant factors in the development of PIs in this group of patients.
10.1016/j.joms.2014.04.018
Impact of head-of-bed elevation angle on the development of pressure ulcers and pneumonia in patients on mechanical ventilation: a systematic review and meta-analysis.
BMC pulmonary medicine
BACKGROUND:Mechanical ventilation is crucial for patient management in intensive care units, but it comes with complications such as pressure ulcers and ventilator-associated pneumonia (VAP). The impact of head-of-bed elevation angles on these complications remains a critical area for investigation. METHODS:This systematic review and meta-analysis followed PRISMA guidelines and involved searches across PubMed, Embase, Web of Science, and Cochrane Library, conducted on September 19, 2023, with no date or language restrictions. We included randomized controlled trials that compared different head-of-bed elevation angles in adult ICU patients on mechanical ventilation. Data were extracted on study characteristics, quality assessed using the Cochrane risk of bias tool, and statistical analyses performed using chi-square tests for heterogeneity and fixed or random-effects models based on heterogeneity results. RESULTS:Six studies met inclusion criteria out of an initial 601 articles. These studies showed minimal heterogeneity (I = 0.0% for pressure ulcers, p = 0.930; and for VAP, p = 0.797), supporting the use of fixed-effect models. Results indicated that a higher elevation angle (45°) significantly increased the risk of pressure ulcers (OR = 1.95, 95% CI: 1.12-3.37, p < 0.05) and decreased the incidence of VAP compared to a lower angle (30°) (OR = 0.51, 95% CI: 0.31-0.84, p < 0.05). CONCLUSIONS:While higher head-of-bed elevation can reduce the risk of VAP in mechanically ventilated patients, it may increase the risk of pressure ulcers. Clinical strategies should carefully balance these outcomes to optimize patient care in ICU settings. REGISTRATION:PROSPERO 2024 CRD42024570232.
10.1186/s12890-024-03270-9