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    Prediction of healing in Category I pressure ulcers by skin blotting with plasminogen activator inhibitor 1, interleukin-1α, vascular endothelial growth factor C, and heat shock protein 90α: A pilot study. Nakai Ayano,Minematsu Takeo,Tamai Nao,Sugama Junko,Urai Tamae,Sanada Hiromi Journal of tissue viability The prevention of progression of Category I pressure ulcers (PUs) to Category II or higher is important, as Category II or higher PUs are open wounds and have a higher infection risk. Prognosis prediction of Category I PUs is necessary to provide successful intensive care for PUs with impaired healing. We focused on skin blotting using plasminogen activator inhibitor 1 (PAI1), interleukin-1α (IL-1α), vascular endothelial growth factor C (VEGF-C), and heat shock protein 90α (HSP90α). This pilot study was conducted at long-term-care and general hospitals to examine the applicability of DESIGN-R and thermography; the feasibility of skin blotting technique; the biomarker candidates, PAI1, IL-1α, VEGF-C, and HSP90α; and sample size for prognosis prediction for Category I PUs. Patients aged >65 years underwent skin blotting, scoring for DESIGN-R, and took thermography images of their Category I PU site. Albumin signals were not detected in one out of three participants. PAI1, IL-1α, VEGF-C, and HSP90α were detected in 19 participants, among whom 11 participants could be followed up after one week. There was no difference in DESIGN-R score and skin surface temperature between normal and impaired healing groups, and the sample size was calculated as 16. In conclusion, the feasibility of skin blotting was confirmed. PAI1, IL-1α, VEGF-C, and HSP90α could be biomarker candidates for prognosis prediction for Category I PU and the combination of VEGF-C and HSP90α could be associated with the prognosis of Category I PU. We need to investigate 842 patients in a future study. 10.1016/j.jtv.2019.02.002
    The Effect of Shear Force on Skin Viability in Patients with Type 2 Diabetes. de Wert Luuk A,Geerts Margot,van der Brug Sander,Adriaansen Laura,Poeze Martijn,Schaper Nicolaas,Bouvy Nicole D Journal of diabetes research Background:Shear is a major risk factor in the development of diabetic foot ulcers, but its effect on the skin of patients with type 2 diabetes mellitus (DM) remains to be elucidated. The aim was to determine skin responses to shear in DM patients with and without diabetic polyneuropathy (DNP). Methods:The forearm skin was loaded with 14.5 N shear (+2.4 kPa pressure) and with 3.5 kPa pressure for 30 minutes in 10 type 2 DM patients without DNP, 10 type 2 DM patients with DNP, and 10 healthy participants. A Sebutape collected IL-1 (measure of tissue damage). A laser Doppler flowmeter measured cutaneous blood cell flux (CBF) as a measure of the reactive hyperaemic skin response. Findings:Reactive hyperaemia and IL-1 release was significantly increased after shear loading in all three groups and was higher compared to the responses to pressure loading. The reactive hyperaemic response after shear loading was impaired in patients with type 2 DM compared to healthy participants but did not differ between patients with and without DNP. The reactive hyperaemic response was negatively correlated with the blood glucose level but did not correlate with the DNP severity score. Interpretation:Shear is important in the development of tissue damage, but the reparative responses to shear are impaired in patients with type 2 DM. DNP was not associated with altered skin responses, suggesting that the loss of protective sensation to sense shear to skin remains a key factor in the development of diabetic foot ulcers in patients with DNP. 10.1155/2019/1973704
    Lack of Association of High Backrest With Sacral Tissue Changes in Adults Receiving Mechanical Ventilation. Grap Mary Jo,Munro Cindy L,Schubert Christine M,Wetzel Paul A,Burk Ruth S,Pepperl Anathea,Lucas Valentina American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:Although higher backrest elevation may be a theoretical risk for integrity of sacral tissues, few data support use of high backrest elevation. OBJECTIVE:To describe the effect of backrest elevation on the integrity of sacral tissue in critically ill adults receiving mechanical ventilation. METHODS:Patients from 3 critical care units (surgical trauma, medical respiratory, and neuroscience) who were expected to have mechanical ventilation for at least 24 hours were intubated and mechanical ventilation was started. Participants were enrolled in the study within 24 hours of intubation. Backrest elevation was continuously measured by using mechanical system- based accelerometers. Integrity of sacral tissue was evaluated by using high-frequency sonography. RESULTS:Data for 84 patients who had measurements of both backrest elevation and skin integrity were available for analysis. General linear models indicated no significant difference among the proportions of time spent at less than 20° ( values: .57 the first 24 hours, .17 the first 48 hours, .81 the first 72 hours), 20° to 30° ( values: .25 the first 24 hours, .08 the first 48 hours, .25 the first 72 hours), or greater than 30° ( values: .62 the first 24 hours, .28 the first 48 hours, .68 the first 72 hours) among participants with no injury, no change in injury, improvement in injury, or injury that worsened. CONCLUSIONS:Level of backrest elevation is not associated with changes in tissue integrity. Body positioning in critically ill patients receiving mechanical ventilation may not be as important or as effective as once thought. 10.4037/ajcc2018419
    Backrest Elevation and Tissue Interface Pressure by Anatomical Location During Mechanical Ventilation. Grap Mary Jo,Munro Cindy L,Wetzel Paul A,Schubert Christine M,Pepperl Anathea,Burk Ruth S,Lucas Valentina American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:Backrest elevations less than 30° are recommended to reduce pressure ulcers, but positions greater than 30° are recommended during mechanical ventilation to reduce risk for ventilator-associated pneumonia. Interface pressure may vary with level of backrest elevation and anatomical location (eg, sacrum, heels). OBJECTIVE:To describe backrest elevation and anatomical location and intensity of skin pressure across the body in patients receiving mechanical ventilation. METHODS:In a longitudinal study, patients from 3 adult intensive care units in a single institution receiving mechanical ventilation were enrolled within 24 hours of intubation from February 2010 through May 2012. Backrest elevation (by inclinometer) and pressure (by a pressure-mapping system) were measured continuously for 72 hours. Mean tissue interface pressure was determined for 7 anatomical areas: left and right scapula, left and right trochanter, sacrum, and left and right heel. RESULTS:Data on 133 patients were analyzed. For each 1° increase in backrest elevation, mean interface pressure decreased 0.09 to 0.42 mm Hg. For each unit increase in body mass index, mean trochanter pressure increased 0.22 to 0.24 mm Hg. Knee angle (lower extremity bent at the knee) and mobility were time-varying covariates in models of the relationship between backrest elevation and tissue interface pressure. CONCLUSIONS:Individual factors such as patient movement and body mass index may be important elements related to risk for pressure ulcers and ventilator-associated pneumonia, and a more nuanced approach in which positioning decisions are tailored to optimize outcomes for individual patients appears warranted. 10.4037/ajcc2016317
    Exploring pressures, tissue reperfusion and body positioning: a pilot evaluation. Coyer F,Clark M,Slattery P,Thomas P,McNamara G,Edwards C,Ingleman J,Stephenson J,Ousey K Journal of wound care OBJECTIVE:To assess the relationship in healthy adults and critically ill patients between: patient position, body mass index (BMI), patient body temperature, interface pressure (IP) and tissue reperfusion (TR). Also to determine the relationship in critically ill patients between: Sequential Organ Failure Assessment (SOFA) score, Braden Scale score for predicting pressure injury risk, Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of disease classification score, IP and TR. METHODS:This study took place in a 27-bed intensive care unit (ICU) of an Australian tertiary hospital. IP and TR outcomes were measured at the sacrum and greater trochanter. Repeated measures analyses of variance (ANOVAs) and doubly multivariate repeated measures ANOVAs were conducted using peak pressure index (PPI), peak time (PT), settled time constant (STC) and normalised hyperaemic area (NHA) measures of TR as outcomes. Participant type, body mass index (BMI), Braden and APACHE II scores and patient body temperature were considered as between-groups factors and covariates. RESULTS:We recruited 23 low- and high-acuity ICU patients and nine healthy adult volunteers. Not all IP readings could be obtained from ICU patients. TR readings were collected from all recruited patients, but not all TR measurements were mutually uncorrelated. Controlling for age, PPI readings differed between participant types (p=0.093), with the highest values associated with high-acuity patients and the lowest with healthy adults; the association was not substantive when controlling for age and BMI. Age was a significant variable (p=0.008), with older participants having higher scores than younger ones. No statistically significant associations between any measured parameter and TR variables were observed. However, temperature was revealed to be related to TR (p=0.091). CONCLUSIONS:Although not powered to detect significant effects, this pilot analysis has determined several associations of importance, with differences in outcomes observed between low- and high-acuity ICU patients; and between ICU patients and healthy volunteers. 10.12968/jowc.2017.26.10.583
    A Prospective, Descriptive, Quality Improvement Study to Investigate the Impact of a Turn-and-Position Device on the Incidence of Hospital-acquired Sacral Pressure Ulcers and Nursing Staff Time Needed for Repositioning Patients. Hall Kimberly D,Clark Rebecca C Ostomy/wound management Patients in critical care areas are at risk for developing hospital-acquired pressure ulcers (HAPUs) due to their physical conditions and limited ability to reposition themselves. A prospective, 2-phase quality improvement study was conducted from September to November 2011 and from February to April 2012 in 1 medical and 1 surgical ICU to investigate the impact of a turn-and-assist device on the incidence of HAPUs and the time and personnel required to reposition patients reported as person/minutes (staff x minutes). A consecutive, convenience sample of patients was selected from newly admitted ICU patients who were at least 18 years old, nonambulatory, and required 2 or more people to assist with turning and repositioning. Sociodemographic data (patient age, gender, height, weight, body mass index, incontinence status); total Braden score and subscores for Activity, Mobility, and Moisture on admission; length of ICU stay and ventilator days; and sacral pressure ulcer incidence and stage and turn-and-assist data were collected. Fifty (50) patients participated in each phase. In phase 1, standard care for positioning included pillows, underpads, standard low-air-loss beds and additional staff as required for turning. In phase 2, the study product replaced standard care repositioning products including pillows; and a larger disposable moisture-wicking underpad (included as part of the turn study project kit) was substituted for the smaller, standard moisture-wicking disposable underpad. Turning procedures were timed with a stopwatch. Data were collected for a total of 32 hours during the observation periods; all patients were followed from admission until discharge from the ICU for a maximum of 14 days. T-tests were used to compare patient characteristics and person-minutes needed for repositioning differences, and Fisher's exact test was used to compare the incidence of sacral HAPUs during phase 1 and phase 2 of the study. No statistically significant sociodemographic or clinical differences were noted between the 2 groups. During phase 1, 14 patients (28%) developed a Stage 2 sacral HAPU. During phase 2, no patients developed a sacral HAPU (P <0.0001). The average time spent for repositioning was 16.34 person/minutes (range 4-60, SD 10.08) during phase 1 and 3.58 minutes (range 1.12-8.48, SD 2.31) during phase 2. The mean difference between person/minutes for the 2 phases was 12.76 minutes (P = 0.0006). In this population of ICU patients, the rate of sacral HAPUs and person/time needed for repositioning were significantly lower following implementation of a turn-and-assist product. Future research is indicated on the effect of this type of product on improving outcomes for patients and making the work of patient care safer and more efficient.
    Potential efficiency of antioxidants to prevent pressure ulcers. A neglected hypothesis. Bonne Claude Medical hypotheses Pressure ulcers are necrotic lesions mainly due to capillary hypoperfusion. It is well known that hypoxia and also subsequent oxygenation at reperfusion provoke the formation of reactive oxygen species (ROS) responsible for cell death. The hypothesis of their participation in the pathogenesis of pressure ulcers has already been tested; several antioxidants have the capacity to inhibit skin necrosis in animal models but their efficiency in preventing bedsores has never been demonstrated in patients. The failure of clinical trials to show the protective activity of some antioxidants does not rule out the involvement of ROS in ischemic ulcers and the potential efficacy of other antioxidants in preventing their formation remains possible. 10.1016/j.mehy.2016.03.012
    Pressure ulcers or moisture lesions: the theatre perspective. Rego A Journal of perioperative practice Pressure ulcers continue to be a cause for concern in the healthcare industry (IHI 2015). Unfortunately older patients are at a greater risk of developing pressure ulcers (Kottner et al 2013); moisture lesions and the presence of other comorbidities could have long term effects on the patient's health and recovery. 10.1177/175045891602600405
    Effects of humidity on skin friction against medical textiles as related to prevention of pressure injuries. Schwartz Danit,Magen Yana Katsman,Levy Ayelet,Gefen Amit International wound journal Sustained pressure, shear forces, and friction, as well as elevated humidity/moisture, are decisive physical factors in the development of pressure injuries (PIs). To date, further research is needed in order to understand the influence of humidity and moisture on the coefficient of friction (COF) of skin against different types of medical textiles. The aim of this work was to investigate the effects of moisture caused by sweat, urine, or saline on the resulting COF of skin against different textiles used in the medical setting in the context of PI prevention. For that purpose, we performed physical measurements of static COFs of porcine skin followed by finite element (FE) computational modelling in order to illustrate the effect of increased COF at the skin on the resulting strains and stresses deep within the soft tissues of the buttocks. The COF of dry skin obtained for the 3 textiles varied between 0.59 (adult diaper) and 0.91 (polyurethane dressing). In addition, the COF increased with the added moisture in all of the tested cases. The results of the FE simulations further showed that increased COF results in elevated strain energy density and shear strain values in the skin and deeper tissues and, hence, in an increased risk for PI development. We conclude that moisture may accelerate PI formation by increasing the COF between the skin and the medical textile, regardless of the type of the liquid that is present. Hence, reduction of the wetness/moisture between the skin and fabrics in patients at a high risk of developing PIs is a key measure in PI prevention. 10.1111/iwj.12937
    Cost-effectiveness Analysis of Nutritional Support for the Prevention of Pressure Ulcers in High-Risk Hospitalized Patients. Tuffaha Haitham W,Roberts Shelley,Chaboyer Wendy,Gordon Louisa G,Scuffham Paul A Advances in skin & wound care OBJECTIVE:To evaluate the cost-effectiveness of nutritional support compared with standard care in preventing pressure ulcers (PrUs) in high-risk hospitalized patients. DESIGN:An economic model using data from a systematic literature review. A meta-analysis of randomized controlled trials on the efficacy of nutritional support in reducing the incidence of PrUs was conducted. PATIENTS:Modeled cohort of hospitalized patients at high risk of developing PrUs and malnutrition simulated during their hospital stay and up to 1 year. INTERVENTIONS:Standard care included PrU prevention strategies, such as redistribution surfaces, repositioning, and skin protection strategies, along with standard hospital diet. In addition to the standard care, the intervention group received nutritional support comprising patient education, nutrition goal setting, and the consumption of high-protein supplements. MAIN OUTCOMES MEASURES:The analysis was from a healthcare payer perspective. Key outcomes of the model included the average costs and quality-adjusted life years. Model results were tested in univariate sensitivity analyses, and decision uncertainty was characterized using a probabilistic sensitivity analysis. MAIN RESULTS:Compared with standard care, nutritional support was cost saving at AU $425 per patient and marginally more effective with an average 0.005 quality-adjusted life years gained. The probability of nutritional support being cost-effective was 87%. CONCLUSIONS:Nutritional support to prevent PrUs in high-risk hospitalized patients is cost-effective with substantial cost savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients. 10.1097/01.ASW.0000482992.87682.4c
    A Retrospective, Descriptive Analysis of Hospital-acquired Deep Tissue Injuries. Tescher Ann N,Thompson Susan L,McCormack Heather E,Bearden Brenda A,Christopherson Mark W,Mielke Catherine L,Sievers Beth A Ostomy/wound management Preventing, identifying, and treating deep tissue injury (DTI) remains a challenge. PURPOSE:The purpose of the current research was to describe the characteristics of DTIs and patient/care variables that may affect their development and outcomes at the time of hospital discharge. METHODS:A retrospective, descriptive, single-site cohort study of electronic medical records was conducted between October 1, 2010, and September 30, 2012, to identify common demographic, intrinsic (eg, mobility status, medical comorbidities, and incontinence), extrinsic (ie, surgical and procedural events, medical devices, head-of-bed elevation), and care and treatment factors related to outcomes of hospital-acquired DTIs; additional data points related to DTI development or descriptive of the sample (Braden Scale scores and subscale scores, hospital length of stay [LOS], intensive care unit [ICU] LOS, days from admission to DTI, time in the operating room, serum albumin levels, support surfaces/specialty beds, and DTI locations) also were retrieved. DTI healing outcomes, grouped by resolved, partial-thickness/stable, and full-thickness/unstageable, and 30 main patient/treatment variables were analyzed using Kruskal-Wallis, chi-squared, and Fischer exact tests. RESULTS:One hundred, seventy-nine (179) DTIs occurred in 141 adult patients (132 in men, 47 in women; mean patient age 64 [range 19-94]). Of those patients, 110 had a history of peripheral vascular disease and 122 had hypertension. Sixty-nine (69) DTIs were documented in patients who died within 1 year of occurrence. Most common DTI sites were the coccyx (47 [26%]) and heel (42 [23%]); 41 (22%) were device-related. Median hospital LOS was 23 (range 4-258) days and median ICU LOS was 12 (range 1-173) days; 40 DTIs were identified before surgery and 120 after a diagnostic or therapeutic procedure. Data for DTI outcome groups at hospital discharge included 28 resolved, 131 partial-thickness/stable, and 20 full-thickness/unstageable; factors significantly different between outcome groups included mechanical ventilation (15/42/12; P = .01), use of a feeding tube (15/46/12; P = .02), anemia (14/30/9; P = .005), history of cerebrovascular accident (12/27/7; P = .03), hospital LOS (67/18/37.5; P <.001), ICU LOS (23/10/12; P = .03), time-to-event (13.5/8/9; P = .001), vasopressor use after DTI (13/31/11; P = .003), low-air-loss surface (10/9/3; P = .005), and device-related (14/24/4; P = .002). CONCLUSION:DTI risk factors mirrored those of other PUs, but progression to full-thickness injury was not inevitable. Early and frequent assessment and timely intervention may help prevent DTI progression.
    Predicting the Risk for Hospital-Acquired Pressure Ulcers in Critical Care Patients. Deng Xiaohong,Yu Ting,Hu Ailing Critical care nurse BACKGROUND:Assessments of risk for pressure ulcers in critical care patients may not include important predictors. OBJECTIVE:To construct risk-prediction models of hospital-acquired pressure ulcers in intensive care patients and compare the models' predictive validities with validity of the Braden Scale. METHODS:Data were collected retrospectively on patients admitted to intensive care from October 2011 through October 2013. Logistic regression and decision trees were used to construct the risk-prediction models. Predictive validity was measured by using sensitivity, specificity, positive and negative predictive values, and area under the curve. RESULTS:With logistic regression analysis, 6 factors were significant independent predictors. With the decision tree, 4 types of high-risk populations were identified. Predictive validity of Braden Scale scores was lower than the validities of the logistic regression and the decision tree models. CONCLUSION:Risk for hospital-acquired pressure ulcers is overpredicted with the Braden Scale, with low specificity and low positive predictive value. 10.4037/ccn2017548
    A Retrospective, Descriptive, Comparative Study to Identify Patient Variables That Contribute to the Development of Deep Tissue Injury Among Patients in Intensive Care Units. Kirkland-Kyhn Holly,Teleten Oleg,Wilson Machelle Ostomy/wound management Deep tissue injury (DTI) may develop in critically ill patients despite implementation of preventive interventions. A retrospective, descriptive study was conducted in a 620-bed, level 1 trauma, academic medical center with 7 adult intensive care units ([ICUs] cardiac surgery, trauma surgery, burn surgery, med-surgery, neurosurgery, medical, and transfer) among patients treated from January 1, 2010 to January 1, 2015. All patients 18 years of age or older that developed a sacral DTI that evolved into a Stage 3, Stage 4, or unstageable hospital-acquired pressure ulcers (HAPU) in the ICU were included. Control group data were obtained from a sample of ICU patients who did not develop a DTI during 1 random day during that time period. Data were extracted from electronic medical records to compare ICU patients that developed a DTI (n = 47; age 55 [range 28-93] years, 28 men) to those who did not develop a DTI (n = 72; age 58.9 [range 18-94] years, 46 men). Twenty-five (25) potential sociodemographic and clinical risk factors were identified from root cause analysis and measured for significance. Systolic and diastolic blood pressure, length of surgery, hematocrit levels, international ratio, dialysis treatments, history of shock or vasopressor use, and total Braden score were significantly (P <.05) different between the general and HAPU population. Braden scores were low for general ICU (15.0 ± 0.4) and HAPU patients (12.9 ± 0.3) (P = 0.03). Multivariate, univariate, and regression analysis showed patients with poor perfusion (low blood pressure) (OR 0.93; 95% CI 0.88-0.99), prolonged surgical procedures (time in surgery OR 1.20; 95% CI 1.07-1.33), or a history of dialysis (OR 4.0; 95% CI 0.060-0.99) and shock (OR 10.0; 95% CI 0.025-0.43) were at greatest risk for the development of DTI evolving into a Stage 3, Stage 4, or unstageable HAPU. For every mm Hg decrease in diastolic blood pressure, the odds of a DTI increased by approximately 7.5% (1/0.93 = 1.075). For every hour increase in surgery, the odds of developing a DTI increased by 20%. These data suggest when all modifiable (Braden Scale-identified) risk factors are addressed, as was the case in this population, patient-related risk factors may be more important for HAPU development in ICU patients than quality of nursing care variables. Future research should focus on the role of and methods to increase perfusion to prevent DTI development, especially during dialysis and surgical procedures.
    Predictive validity of the Braden scale for assessing risk of developing pressure ulcers and dependence-related lesions. Roca-Biosca A,Rubio-Rico L,Fernández M I de Molina,Grau N García,Garijo G Tuset,Fernández F P García Journal of wound care OBJECTIVE:In 2014, a new theoretical model explained the mechanism of the development of pressure ulcers (PUs) and that of seven types of lesions known as dependence-related lesions (DRL). The aim of this study was to calculate the incidence of DRL that have been classified as PUs and to check the predictive validity of the Braden scale for assessing DRL in accordance with the new theoretical model in an intensive care unit (ICU). Method This longitudinal, prospective study was conducted in a Spanish ICU. The patients were monitored for 14 days in the ICU until they developed DRL, died, or were discharged. The patients' risk of developing DRL was assessed each day using the Braden scale. The following parameters were taken as reference for validating the scale: sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV, respectively), relative risk (RR) and the area under the receiver operating characteristic (ROC) curve. RESULTS:Of the 295 patients included in the study, 27.5% developed DRL, which 50.6% were categorised as PUs, 17.3% caused by moisture, and 13.6% caused by friction. The rest were categorised as caused by a combination of factors. Risk according to the Braden scale was greater in the group of patients with DRL than in the group of patients without. The highest risk score provided the best predictive validity parameters for the DRL (Se 0.90, Sp 0.26, PPV 0.31, NPV 0.78 and RR 3.15 [confidence interval (CI) 95%: 1.42-6.96]). These vaules show the individuals at risk are well detected, although it is at the expense of generating a number of false positive cases. CONCLUSIONS:The Braden scale has demonstrated a moderate capacity for predicting PUs and DRL caused by moisture, but no capacity for predicting DRL caused by friction. 10.12968/jowc.2017.26.9.528
    Developing a Mobile App for Prevention and Treatment of Pressure Injuries. Salomé Geraldo Magela,Ferreira Lydia Masako Advances in skin & wound care OBJECTIVE:This descriptive study describes the planning and development of a mobile application (app) for prevention and treatment of pressure injuries for use by providers in a university research center. The app delineates risk factors for pressure injury development, provides an evaluation of the wound, recommends wound cleansing procedures, performs pressure injury staging, and recommends treatment interventions. METHODS:A mobile app was developed using a contextualized instructional design, which involves a constructivist proposal and planning, developing, and applying specific didactic situations, thus incorporating mechanisms that favor contextualization. A literature search was conducted to identify relevant studies for the construction of the mobile app. The development process involved the selection of app tools, definition of the navigation structure, and planning of the environment configuration. The environment for downloading the app software on the Internet and installing it on the mobile device was created. MAIN RESULTS:The literature search yielded 18 articles, 2 books, and 1 master's degree thesis. A mobile app was created with an easy-to-use graphic interface. The app stores the patient's demographic characteristics and provides an evaluation of his/her wound, a list of risk factors for pressure injury development, wound cleansing procedures, and treatment interventions. CONCLUSIONS:The developed app may be useful in clinical practice, helping to prevent pressure injuries and promote select nursing interventions for the treatment of patients with pressure injury. 10.1097/01.ASW.0000529693.60680.5e
    Related factors to semi-recumbent position compliance and pressure ulcers in patients with invasive mechanical ventilation: An observational study (CAPCRI study). Llaurado-Serra Mireia,Ulldemolins Marta,Fernandez-Ballart Joan,Guell-Baro Rosa,Valentí-Trulls Teresa,Calpe-Damians Neus,Piñol-Tena Angels,Pi-Guerrero Mercedes,Paños-Espinosa Cristina,Sandiumenge Alberto,Jimenez-Herrera María F, International journal of nursing studies BACKGROUND:Semi-recumbent position is recommended to prevent ventilator-associated pneumonia. Its implementation, however, is below optimal. OBJECTIVES:We aimed to assess real semi-recumbent position compliance and the degree of head-of-bed elevation in Spanish intensive care units, along with factors determining compliance and head-of-bed elevation and their relationship with the development of pressure ulcers. Finally, we investigated the impact that might have the diagnosis of pressure ulcers in the attitude toward head-of-bed elevation. METHODS:We performed a prospective, multicenter, observational study in 6 intensive care units. Inclusion criteria were patients ≥18 years old and expected to remain under mechanical ventilator for ≥48h. Exclusion criteria were patients with contraindications for semi-recumbent position from admission, mechanical ventilation during the previous 7 days and prehospital intubation. Head-of-bed elevation was measured 3 times/day for a maximum of 28 days using the BOSCH GLM80(®) device. The variables collected related to patient admission, risk of pressure ulcers and the measurements themselves. Bivariate and multivariate analyses were carried out using multiple binary logistic regression and linear regression as appropriate. Statistical significance was set at p<0.05. All analyses were performed with IBM SPSS for Windows Version 20.0. RESULTS:276 patients were included (6894 measurements). 45.9% of the measurements were <30.0°. The mean head-of-bed elevation was 30.1 (SD 6.7)° and mean patient compliance was 53.6 (SD 26.1)%. The main reasons for non-compliance according to the staff nurses were those related to the patient's care followed by clinical reasons. The factors independently related to semi-recumbent position compliance were intensive care unit, ventilation mode, nurse belonging to the research team, intracranial pressure catheter, beds with head-of-bed elevation device, type of pathology, lateral position, renal replacement therapy, nursing shift, open abdomen, abdominal vacuum therapy and agitation. Twenty-five patients (9.1%) developed a total of 34 pressure ulcers. The diagnosis of pressure ulcers did not affect the head-of-bed elevation. In the multivariate analysis, head-of-bed elevation was not identified as an independent risk factor for pressure ulcers. CONCLUSIONS:Semi-recumbent position compliance is below optimal despite the fact that it seems achievable most of the time. Factors that affect semi-recumbent position include the particular intensive care unit, abdominal conditions, renal replacement therapy, agitation and bed type. Head-of-bed elevation was not related to the risk of pressure ulcers. Efforts should be made to clarify semi-recumbent position contraindications and further analysis of its safety profile should be carried out. 10.1016/j.ijnurstu.2016.06.002
    Pressure Ulcers: Developing Clinical Indicators in Evidence-based Practice. A Prospective Study. Tsaras Konstantinos,Chatzi Maria,Kleisiaris Christos F,Fradelos Evangelos C,Kourkouta Lambrini,Papathanasiou Ioanna V Medical archives (Sarajevo, Bosnia and Herzegovina) AIMS AND OBJECTIVES:It is widely recognized that Intensive Care Unit (ICU) patients have a greater likelihood of developing pressure ulcers in comparison to hospital or home care patients. Accordingly, this study aimed to evaluate whether specific clinical characteristics could be used as clinical indicators towards pressure ulcers prevention. METHOD:We monitored 210 hospitalized ICU patients during a 12-month period. Pressure ulcers were assessed following the current guidelines. Clinical characteristics such as gender, age, hospitalized days, hemodialysis treatment, hematocrit, and serum albumin levels were considered as the most common predictors for pressure ulcers development. The significance of associations was controlled using multiple logistic regression after adjusting for clinical characteristics and was presented as adjusted odds ratio (AOR). RESULTS:The prevalence of pressure ulcers was 24.3%. Logistic regression revealed that patients with increased age AOR=1.04; (CI: 1.01-1.07) and last-long hospitalization AOR=1.17; (CI: 1.11-1.23) were significantly more likely to present pressure ulcers compared to the younger ones and patients with less length of stay, respectively. We also found that patients under hemodialysis treatment were more likely to present pressure ulcers AOR=4.09; (CI: 1.12-14.98) compared to patients that did not underwent hemodialysis and the risk of pressure ulcers development was decreased by 9% for every single unit of hematocrit value increase AOR=0.91; (CI: 0.82-0.99). CONCLUSION:Our data analysis confirms that the clinical characteristics that were studied are independently associated with pressure ulcers development, and therefore, it is a crucial incentive to consider that these specific clinical characteristics are important indicators in the evidence-based practice. 10.5455/medarh.2016.70.379-383
    Pressure injuries in elderly with acute myocardial infarction. Komici Klara,Vitale Dino F,Leosco Dario,Mancini Angela,Corbi Graziamaria,Bencivenga Leonardo,Mezzani Alessandro,Trimarco Bruno,Morisco Carmine,Ferrara Nicola,Rengo Giuseppe Clinical interventions in aging OBJECTIVES:To assess pressure injury (PI) incidence among patients hospitalized for acute myocardial infarction (AMI) in an intensive coronary care unit (ICCU) and to detect the impact of specific risk factors on the development of PI in this clinical setting. PATIENTS AND METHODS:Prospective cohort study in ICCU setting. Patients admitted for AMI: patients mean age 67.5±11.5 years (n=165). Norton Scale, Mini Nutritional Assessment (MNA), demographic, clinical and biochemical data collected at the time of ICCU admission have been tested in a logistic model to assess the odds ratios (ORs) of PI risk development. The jackknifed area under the receiver operating characteristic curve (AUC) and the decision curve analysis have been employed to assess the additive predictive value of a factor. RESULTS:Twenty-seven (16.3%) patients developed PIs. An increased PI risk was associated with advanced age (OR =2.5 every 10-year increase; 95% CI =1.1-5.7), while probability of PI development was reduced in patients with higher left ventricular ejection fraction (LVEF) (OR =0.4 every 5% increase; 95% CI =0.24-0.66), MNA score (OR =0.65 every unit change; 95% CI =0.44-0.95) and Norton Scale score (OR =0.7 every unit change; 95% CI =0.57-0.88). The AUC and the decision curve analysis showed that LVEF inclusion improved the discrimination power and the clinical net benefit of the final model. CONCLUSION:Age, LVEF, Norton Scale and MNA scores have a strong and independent clinical value as predictors of in-hospital PI development in patients with AMI. This finding has the potential to improve the clinical management of patients admitted in ICCU. 10.2147/CIA.S135676
    Financial and Clinical Risk Evaluation of Pressure Injuries in US Hospitals: A Business Case for Initiating Quality Improvement. Au Yunghan,Wang Sheila C Wounds : a compendium of clinical research and practice INTRODUCTION:Pressure injuries (PIs) are a serious, avoidable condition that affect many patients during hospital stays. Yet, to date, there is no comprehensive assessment of the financial and clinical risks of PIs. OBJECTIVE:This study evaluates the cost of treatment, impact of reimbursement policies, and clinical consequences of PIs for US hospitals. METHODS:A financial and clinical calculator was created to estimate the impact of PI prevention using a traditional literature review to drive assumptions. RESULTS:Two drivers of hospital revenue loss resulting from PIs were identified: nonpayment for PI treatment by health insurance providers and personal injury litigation. Increased hospital length of stay (LOS) and patient mortality associated with PIs further contributed to negative consequences. For an average 160-bed hospital, the authors estimated an annual total financial risk of $5.97 million, 911 days added to LOS, and 16.4 deaths related to avoidable PIs. CONCLUSIONS:Results of this analysis will be useful for health care organizations implementing quality improvement initiatives and new technologies, such as digital wound care management systems, to reduce the prevalence of PIs, thereby protecting patients and mitigating financial and clinical risks.
    Bacteremia associated with pressure ulcers: a prospective cohort study. Espejo Elena,Andrés Marta,Borrallo Rosa-Maria,Padilla Emma,Garcia-Restoy Enric,Bella Feliu, European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology The objective of this study is to evaluate the clinical and microbiological characteristics of bacteremia associated with pressure ulcers (BAPU) and factors associated with mortality. This study was a prospective observational cohort study of patients with BAPU at a teaching hospital between January 1984 and December 2015. Fifty-six episodes were included. The incidence of BAPU decreased from 2.78 cases per 10,000 hospital discharges in the period from 1984 to 1999 to 1.05 cases per 10,000 hospital discharges in the period from 2000 to 2015 (p < 0.001). In 20 cases (35.7%), the bacteremia was hospital-acquired, since it occurred more than 48 h after the hospital admission. The most frequent microorganisms isolated in blood culture were Staphylococcus aureus, Proteus spp., and Bacteroides spp. The bacteremia was polymicrobial in 14 cases (25.0%). Overall mortality was observed in 23 episodes (41.1%). The risk factors independently associated with mortality were hospital-acquired bacteremia (odds ratio [OR] 5.51, 95% confidence interval [95%CI] 1.24-24.40), polymicrobial bacteremia (OR 6.88, 95%CI 1.22-38.89), and serum albumin <23 g/L (OR 8.00, 95%CI 1.73-37.01). BAPU is an uncommon complication of pressure ulcers and is mainly caused by S. aureus, Proteus spp., and Bacteroides spp. In our hospital, the incidence of BAPU has declined in recent years, coinciding with the implementation of a multidisciplinary team aimed at preventing and treating chronic ulcers. Mortality rate is high, and hospital-acquired bacteremia, polymicrobial bacteremia, and serum albumin < 23 g/L are associated with increased mortality. 10.1007/s10096-018-3216-8
    Pressure Injuries in Critical Care: A Survey of Critical Care Nurses. Cox Jill,Schallom Marilyn Critical care nurse BACKGROUND:Critical care nurses must be able to skillfully balance the prevention of adverse events such as pressure injuries in an environment with multiple competing and lifesaving technologies that often take precedent. Despite strategies to prevent them, pressure injuries do occur in intensive care unit patients, and consensus is building that some pressure injuries are unavoidable. OBJECTIVES:To determine critical care nurses' attitudes toward prevention of pressure injury and the perceptions of frontline critical care nurses of specific risk factors associated with unavoidable pressure injuries. METHODS:A descriptive cross-sectional survey design was used. An online survey was posted on the newsletter website of the American Association of Critical-Care Nurses in January 2016. RESULTS:An invitation to participate in the study was emailed to more than 3000 members of the association; 333 nurses responded, for a response rate of approximately 11%. Among the responders, 73% were employed as bedside critical care nurses. More than half (67%) thought that pressure injuries are avoidable, and 66% disagreed that pressure injury prevention was of less interest than other aspects of critical care. The top 2 risk factors for unavoidable pressure injuries were impaired tissue perfusion and impaired tissue oxygenation. CONCLUSION:Critical care nurses are steadfast stewards of safe patient care and think that pressure injury prevention is a crucial aspect of the care they deliver every day. The findings on risk factors for unavoidable pressure injuries mirrored those of experts and provide a layer of support for these factors. 10.4037/ccn2017928
    Adult pressure area care: preventing pressure ulcers. Mitchell Aby British journal of nursing (Mark Allen Publishing) Pressure ulcers (PUs) are caused by tissue damage when the blood supply to an area of skin is diminished as a result of pressure. Although most pressure ulcers are preventable, all patients are at risk. Nurses have a central role in prevention and management of pressure areas. They should be able to assess patients' risk of developing PUs using evidence-based practice, recognised risk assessment tools and by completing a holistic assessment. Nurses must be able to identify the risk factors associated with developing PUs and implement appropriate measures to deliver harm-free care. Repositioning techniques, monitoring and ongoing care strategies are essential for pressure ulcer prevention in practice. 10.12968/bjon.2018.27.18.1050
    The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment. Kim Chul-Gyu,Park Seungmi,Ko Ji Woon,Jo Sungho Journal of tissue viability AIM:The purpose of this study was to examine the relationship of subepidermal moisture and early stage pressure injury by visual skin assessment in elderly Korean. METHODS:Twenty-nine elderly participated at a particular nursing home. Data were collected for 12 weeks by one wound care nurse. Visual skin assessment and subepidermal moisture value were measured at both buttocks, both ischia, both trochanters, sacrum, and coccyx of each subject once a week. RESULTS:Subepidermal moisture value of stage 1 pressure injury was significantly higher than that of no injury and blanching erythema. After adjustment with covariates, odds ratios of blanching erythema to normal skin and stage 1 pressure injury to blanching erythema/normal skin were statistically significant (p < 0.05). Odds ratio of blanching erythema to normal skin was 1.003 (p = .047) by 1-week prior subepidermal moisture value, and that of concurrent subepidermal moisture value was 1.004 (p = .011). Odds ratio of stage 1 pressure injury to normal skin/blanching erythema was 1.003 (p = .005) by 1-week prior subepidermal moisture value, and that for concurrent subepidermal moisture value was 1.007 (p = .030). Subepidermal moisture was associated with concurrent and future (1 week later) skin damage at both trochanters. CONCLUSION:Subepidermal moisture would be used to predict early skin damage in clinical nursing field for the effective pressure injury prevention. 10.1016/j.jtv.2018.05.002
    Effects of Hemodynamic Factors and Oxygenation on the Incidence of Pressure Ulcers in the ICU. Soodmand Mostafa,Moghadamnia Mohammad Taghi,Aghaei Iraj,Ghasemzadeh Golshan,Kazemnejad Lili Ehsan,Homaie Rad Enayatollah Advances in skin & wound care OBJECTIVE:To investigate the roles of hemodynamic factors and oxygenation on the incidence of pressure ulcers in patients in the ICU on mechanical ventilation. METHODS:This prospective analytical cross-sectional study was performed in several ICUs for a period of 8 months in Iran. Researchers checked patients for pressure ulcers on a daily basis. They collected demographic, hemodynamic, and oxygenation data until a pressure ulcer occurred, the patient's artificial airway was removed, the patient died, or the patient was discharged. RESULTS:From August 2017 to February 2018, a total of 2,581 patients were admitted to the study ICUs; of these, 133 patients were eligible for the study. The results indicated that 41.4% (n = 55) of the patients ended up with pressure ulcers. Investigation of the variables using a Cox regression model showed that, among other variables considered in this study, age, mean arterial pressure, and positive end-expiratory pressure in the mechanical ventilator can contribute to the risk of pressure ulcers. CONCLUSIONS:Providers should pay attention to changes in hemodynamic parameters, especially mean arterial pressure; carefully determine the most appropriate positive end-expiratory pressure for patients connected to mechanical ventilation; and take special care of susceptible groups such as older adults and hospitalized patients to decrease the incidence of pressure ulcers. 10.1097/01.ASW.0000553599.20444.f4
    Nursing care missed in patients at risk of or having pressure ulcers. Valles Jonathan Hermayn Hernández,Monsiváis María Guadalupe Moreno,Guzmán Ma Guadalupe Interial,Arreola Leticia Vázquez Revista latino-americana de enfermagem Objective:to determine the nursing care missed as perceived by the nursing staff and its relation with the nursing care missed identified in the assessment of patients at risk of or having pressur ulcers. Method:descriptive correlation study. The participants were 161 nurses and 483 patients from a public hospital. The MISSCARE survey was used in combination with a Nursing Care Assessment Form for Patients at Risk of or having pressure ulcers. For the analysis, descriptive and inferential statistics were used. Results:the nursing staff indicated greater omission in skin care (38.5%), position change (31.1%) and the registration of risk factors for the development of pressure ulcers (33.5%). The nursing care missed identified in the assessment related to the use of pressure relief on bony prominences and drainage tubes interfering in the patient's movements (both with 58.6%) and the use of pneumatic mattresses (57.6%). Conclusion:a high percentage of nursing care missed was found according to the staff's perception. Nevertheless, the assessment of the nursing care missed was much higher. No significant relation was found between both. Therefore, it is a priority to reflect on the importance of objective patient assessments. 10.1590/1518-8345.1462.2817
    Predicting Pressure Injury in Critical Care Patients: A Machine-Learning Model. Alderden Jenny,Pepper Ginette Alyce,Wilson Andrew,Whitney Joanne D,Richardson Stephanie,Butcher Ryan,Jo Yeonjung,Cummins Mollie Rebecca American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:Hospital-acquired pressure injuries are a serious problem among critical care patients. Some can be prevented by using measures such as specialty beds, which are not feasible for every patient because of costs. However, decisions about which patient would benefit most from a specialty bed are difficult because results of existing tools to determine risk for pressure injury indicate that most critical care patients are at high risk. OBJECTIVE:To develop a model for predicting development of pressure injuries among surgical critical care patients. METHODS:Data from electronic health records were divided into training (67%) and testing (33%) data sets, and a model was developed by using a random forest algorithm via the R package "randomforest." RESULTS:Among a sample of 6376 patients, hospital-acquired pressure injuries of stage 1 or greater (outcome variable 1) developed in 516 patients (8.1%) and injuries of stage 2 or greater (outcome variable 2) developed in 257 (4.0%). Random forest models were developed to predict stage 1 and greater and stage 2 and greater injuries by using the testing set to evaluate classifier performance. The area under the receiver operating characteristic curve for both models was 0.79. CONCLUSION:This machine-learning approach differs from other available models because it does not require clinicians to input information into a tool (eg, the Braden Scale). Rather, it uses information readily available in electronic health records. Next steps include testing in an independent sample and then calibration to optimize specificity. 10.4037/ajcc2018525
    Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable. Pittman Joyce,Beeson Terrie,Dillon Jill,Yang Ziyi,Cuddigan Janet American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:Despite prevention strategies, hospital-acquired pressure injuries (HAPIs) continue to occur, especially in critical care, raising the question whether some pressure injuries are unavoidable. OBJECTIVES:To determine the proportion of HAPIs among patients in critical and progressive care units that are unavoidable, and to identify risk factors that differentiate avoidable from unavoidable HAPIs. METHODS:This study used a descriptive retrospective design. Data collected included demographic information, Braden Scale scores, clinical risk factors, and preventive interventions. The Pressure Ulcer Prevention Inventory was used to categorize HAPIs as avoidable or unavoidable. RESULTS:A total of 165 patients participated in the study. Sixty-seven HAPIs (41%) were unavoidable. Participants who had congestive heart failure (odds ratio [OR], 0.22; 95% CI, 0.06-0.76; = .02), were chemically sedated (OR, 0.38; 95% CI, 0.20-0.72; = .003), had systolic blood pressure below 90 mm Hg (OR, 0.52; 95% CI, 0.27-0.99; = .047), and received at least 1 vasopressor (OR, 0.44; 95% CI, 0.23-0.86; = .01) were less likely to have an unavoidable HAPI. Those with bowel management devices were more likely to have an unavoidable HAPI (OR, 2.19; 95% CI, 1.02-4.71; = .04). When length of stay was incorporated into the regression model, for each 1-day increase in stay, the odds of an unavoidable pressure injury developing increased by 4% (OR, 1.04; 95% CI, 1.002-1.08; = .04). Participants who had a previous pressure injury were 5 times more likely to have an unavoidable HAPI (OR, 5.27; 95% CI, 1.20-23.15; = .03). CONCLUSIONS:Unavoidable HAPIs do occur; moreover, when preventive interventions are not documented and implemented appropriately, avoidable HAPIs occur. 10.4037/ajcc2019264
    Midrange Braden Subscale Scores Are Associated With Increased Risk for Pressure Injury Development Among Critical Care Patients. Alderden Jenny,Cummins Mollie Rebecca,Pepper Ginette Alyce,Whitney JoAnne D,Zhang Yingying,Butcher Ryan,Thomas Donna Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society PURPOSE:The purpose of the current study was to examine the relationship between pressure injury development and the Braden Scale for Pressure Sore Risk subscale scores in a surgical intensive care unit (ICU) population and to ascertain whether the risk represented by the subscale scores is different between older and younger patients. DESIGN:Retrospective review of electronic medical records. SUBJECTS AND SETTING:The sample comprised patients admitted to the ICU at an academic medical center in the Western United States (Utah) and Level 1 trauma center between January 1, 2008 and May 1, 2013. Analysis is based on data from 6377 patients. METHODS:Retrospective chart review was used to determine Braden Scale total and subscale scores, age, and incidence of pressure injury development. We used survival analysis to determine the hazards of developing a pressure injury associated with each subscale of the Braden Scale, with the lowest-risk category as a reference. In addition, we used time-dependent Cox regression with natural cubic splines to model the interaction between age and Braden Scale scores and subscale scores in pressure injury risk. RESULTS:Of the 6377 ICU patients, 214 (4%) developed a pressure injury (stages 2-4, deep tissue injury, or unstageable) and 516 (8%) developed a hospital-acquired pressure injury of any stage. With the exception of the friction and shear subscales, regardless of age, individuals with scores in the intermediate-risk levels had the highest likelihood of developing pressure injury. CONCLUSION:The relationship between age, Braden Scale subscale scores, and pressure injury development varied among subscales. Maximal preventive efforts should be extended to include individuals with intermediate Braden Scale subscale scores, and age should be considered along with the subscale scores as a factor in care planning. 10.1097/WON.0000000000000349
    Specialty Linens and Pressure Injuries in High-Risk Patients in the Intensive Care Unit. Freeman Regi,Smith Andrew,Dickinson Sharon,Tschannen Dana,James Shandra,Friedman Candace American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:The cardiovascular and surgical intensive care units had the highest unit-acquired pressure injury rates at an institution. Patients in these units had multiple risk factors for pressure injuries. Various interventions had been used to minimize pressure injuries, with limited results. OBJECTIVES:To evaluate the effect of specialty linens on the rate of pressure injuries in high-risk patients. The specialty linen was a synthetic silklike fabric that addressed the microclimate surrounding the patient, with the purpose of minimizing friction, shear, moisture, and heat. METHODS:The specialty linen was tried on 24 beds in the cardiovascular intensive care unit and 20 beds in the surgical intensive care unit, including sheets, underpads, gowns, and pillow cases. Data obtained from a retrospective review of electronic health records were compared for 9 months before and 10 months after specialty linens were implemented. RESULTS:Total unit-acquired pressure injury rates for both units combined declined from 7.7% (n = 166) before to 5.3% (n = 95) after the intervention. The intervention was associated with a significant reduction in posterior (coccyx, sacrum, back, buttock, heel, and spine) pressure injury rates, from 5.2% (n = 113) before to 2.8% (n = 51) after specialty linens were implemented ( < .001). CONCLUSION:Addressing the microclimate, friction, and shear by using specialty linens reduces the number of posterior pressure injuries. The use of specialty linens in addition to standard techniques for preventing pressure injuries can help prevent pressure injuries from developing in high-risk patients in intensive care units. 10.4037/ajcc2017530
    Are pressure injuries related to skin failure in critically ill patients? Nowicki Jake L,Mullany Daniel,Spooner Amy,Nowicki Tracy A,Mckay Peta M,Corley Amanda,Fulbrook Paul,Fraser John F Australian critical care : official journal of the Confederation of Australian Critical Care Nurses BACKGROUND:Pressure injuries contribute significantly to patient morbidity and healthcare costs. Critically ill patients are a high risk group for pressure injury development and may suffer from skin failure secondary to hypoperfusion. The aim of this study was to report hospital acquired pressure injury incidence in intensive care and non-intensive care patients; and assess the clinical characteristics and outcomes of ICU patients reported as having a hospital acquired pressure injury to better understand patient factors associated with their development in comparison to ward patients. METHODS:The setting for this study was a 630 bed, government funded, tertiary referral teaching hospital. A secondary data analysis was undertaken on all patients with a recorded PI on the hospital's critical incident reporting systems and admitted patient data collection between July 2006 to March 2015. RESULTS:There were a total of 5280 reports in 3860 patients; 726 reports were intensive care patients and 4554 were non-intensive care patients, with severe hospital acquired PI reported in 22 intensive care patients and 54 non-intensive care patients. Pressure injury incidence increased in intensive care patients and decreased in non-intensive care patients over the study period. There were statistically significant differences in the anatomical location of severe hospital acquired pressure injuries between these groups (p=0.008). CONCLUSION:Intensive care patients have greater than 10-fold higher hospital acquired pressure injury incidence rates compared to other hospitalised patients. The predisposition of critically ill patients leaves them susceptible to pressure injury development despite implementation of pressure injury prevention strategies. Skin failure appears to be a significant phenomenon in critically ill patients and is associated with the use of vasoactive agents and support systems such as extra corporeal membrane oxygenation and mechanical ventilation. 10.1016/j.aucc.2017.07.004
    Predictors of Pressure Injuries in a Critical Care Unit in Lebanon: Prevalence, Characteristics, and Associated Factors. El-Marsi Jihad,Zein-El-Dine Salah,Zein Bana,Doumit Rita,Kurdahi Badr Lina Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society PURPOSE:The purpose of this study was to identify factors associated with pressure injury in a medical-surgical intensive care unit (MSICU). DESIGN:Retrospective review of medical records. SUBJECTS AND SETTING:We reviewed the medical records of 145 patients who developed a new pressure injury in the MSICU of a 420-bed university medical center in Lebanon. METHODS:Medical records of all patients cared for in the MSICU from December 2014 to June 2017 were reviewed by a research assistant using a standardized form. We extracted potential risk factors for pressure injury including sex, age, weight upon admission, weight at discharge, length of MSICU stay, episodes of hypotension, administration of inotropes/vasopressors, admitting diagnosis, comorbid conditions, and cumulative scores on the Braden Scale for Pressure Sore Risk. The outcome variable was development of any new pressure injury during their stay in our intensive care unit. RESULTS:Forty-nine patents (33.7%) developed a new pressure injury. Bivariate analysis found statistically significant associations between pressure injury occurrences and administration of vasopressors (odds ratio [OR] = 0.42; 95% confidence interval = 0.29-0.87; P = .02), the administration of dopamine (OR = 0.20; 95% confidence interval = 0.04-0.94; P = .04), and hospital-acquired pressure injury. Among the continuous variables, analysis revealed significant relationships between weight at discharge (t = 2.31, P = .02), MSICU length of stay (t = 5.30; P = .000), cumulative Braden Scale score (t = 3.06; P = .002), hypotension (t =-2.74; P = .007), and development a new pressure injury. Multivariate analysis indicated that length of stay (β= -.110; P = .002), administration of vasopressors (β=-.266; P = .029), and total hours of hypotension (β=-.53; P = .041) were significant predictors of pressure injury. CONCLUSIONS:Vasopressor use, hypotension, and length of stay were associated with an increased likelihood of pressure injury in adults managed in an MSICU. None of these factors is specifically evaluated during completion of the Braden Scale for Pressure Sore Risk. Based on these findings we recommend development of a pressure injury scale specific to critically ill adults. 10.1097/WON.0000000000000415
    Reducing the Risk for Pressure Injury During Combat Evacuation. Bridges Elizabeth,Whitney JoAnne D,Burr Robert,Tolentino Ernesto Critical care nurse BACKGROUND:Combat casualties undergoing aeromedical evacuation are at increased risk for pressure injuries. The risk factors pressure and shear are potentially modifiable via solutions appropriate for en route care. OBJECTIVES:To compare transcutaneous oxygen levels and skin temperatures in healthy participants under offloaded (side lying) and loaded (supine or supine with 30° backrest elevation) under 4 conditions: control (no intervention), Mepilex sacral and heel dressings, LiquiCell pad, and Mepilex plus LiquiCell. METHODS:Participants were randomly assigned to 4 groups according to ideal body weight. Backrest positions were randomized. Transcutaneous oxygen level and temperature were measured on the sacrum and the heel; skin interface pressure was measured with an XSensor pressure imaging system. Measurements were obtained for 5 minutes at baseline (offloaded), 40 minutes with participants supine, and 15 minutes offloaded. RESULTS:In the 40 healthy participants, interface pressure, transcutaneous oxygen level, and skin temperature did not differ between the 4 groups. Peak interface pressures were approximately 43 mm Hg for the sacrum and 50 mm Hg for the heel. Sacral transcutaneous oxygen level differed significantly between unloaded (mean, 79 mm Hg; SD, 16.5) and loaded (mean, 57 mm Hg; SD, 25.2) conditions ( < .001) in a flat position (mean, 85.2 mm Hg; SD, 13.6) and with 30° backrest elevation (mean, 66.7 mm Hg; SD, 24.2) conditions ( < .001). Results for the heels and the sacrum were similar. Sacral skin temperature increased significantly across time (approximately 1.0°C). CONCLUSIONS:The intervention strategies did not differ in prevention of pressure injuries. 10.4037/ccn2018223
    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. Fulbrook Paul,Anderson Alissa Journal of advanced nursing AIM:To test the psychometric properties of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index. BACKGROUND:Pressure injury risk assessment is a crucial aspect in determining the relative risk of patients and the need for preventative intervention. In the intensive care setting there are few risk assessment scales that have been developed specifically for critically ill patients. DESIGN:Instrument development. METHODS:A convenience sample of 26 intensive care patients was used. Data were collected in December 2012. Five intensive care nurses scored each patient with all four scales. Intraclass correlation coefficients and standard errors of measurement were used to assess inter-rater reliability and agreement of the sum, risk category and item scores. Convergent validity of the COMHON Index was investigated by examining correlations between the sum scores and similar constructs of the scales. RESULTS:Inter-rater reliability of the COMHON Index was higher than the other scales and strong correlations were found between it and the Braden and Norton scales but not the Waterlow score. Two items common to all scales (mobility; neurological status) demonstrated significant correlations between the COMHON, Braden and Norton scales but not the Waterlow score. One item (nutrition) was significantly correlated between the COMHON and Braden scales. CONCLUSION:Inter-rater reliability and agreement of the COMHON Index were the highest of the four scales, with the Norton and Braden performing similarly and the Waterlow score the least well. The strong and significant associations between the Braden, COMHON and Norton scales suggest they are measuring similar constructs. 10.1111/jan.12825
    The Challenge of Predicting Pressure Ulcers in Critically Ill Patients. A Multicenter Cohort Study. Ranzani Otavio T,Simpson Evelyn Senna,Japiassú André M,Noritomi Danilo Teixeira, Annals of the American Thoracic Society RATIONALE:Pressure ulcers are preventable events. Critically ill patients are particularly vulnerable. The Braden scale has been used to identify hospitalized patients at high risk for the development of pressure ulcers; however, this predictive tool has not been adequately validated for critically ill patients. OBJECTIVES:We aimed to validate and improve the Braden scale for critically ill patients by adding clinical variables to the original scale. METHODS:We conducted a cohort study in 12 intensive care units (ICUs) within a network of hospitals in Brazil during 2013. We excluded patients who stayed less than 48 hours, patients with one or more pressure ulcers at admission, and those who developed a pressure ulcer within the first 48 hours. We evaluated the Braden scale and clinical variables through a competing risk analysis. Discrimination and calibration were evaluated using the Concordance index (C-index) and a calibration plot, respectively. We used bootstrapping to assess internal validation. MEASUREMENTS AND MAIN RESULTS:Our primary outcome was incident pressure ulcer within 30 days of ICU admission. We analyzed 9,605 patients and observed 157 pressure ulcers (rate of 3.33 pressure ulcers/1,000 patient-days). The majority of pressure ulcers were detected at stage I or II (28.7 and 66.2%, respectively). The Braden scale had good discrimination (C-index, 0.753; 95% confidence interval, 0.712-0.795), although its performance decreased for the most severely ill patients. We derived a modified predictive tool by adding eight clinical variables to the Braden scale: age, sex, diabetes mellitus, hematological malignancy, peripheral artery disease, hypotension at ICU admission, and need for mechanical ventilation or renal replacement therapy in the first 24 hours after ICU admission. The derived score had better discrimination and calibration than the original Braden scale. The best score cutoff was at least 6 points, with a sensitivity of 87% and a specificity of 71%. CONCLUSIONS:The original Braden scale measured at ICU admission is a valuable tool for pressure ulcer prediction, although it is not accurate for severely ill patients. To overcome the limitations of the original scale, we derived a modified score with better performance, which may identify high-risk ICU patients and support target interventions. External validation of the proposed clinical prediction score is needed. 10.1513/AnnalsATS.201603-154OC
    A Model of Pressure, Oxygenation, and Perfusion Risk Factors for Pressure Ulcers in the Intensive Care Unit. Bly Deborah,Schallom Marilyn,Sona Carrie,Klinkenberg Dean American journal of critical care : an official publication, American Association of Critical-Care Nurses BACKGROUND:Although most intensive care patients are at risk for pressure ulcers, not all experience such ulcers. OBJECTIVE:To examine a model of variables related to extrinsic and intrinsic pressure on skin and underlying tissues, oxygenation, perfusion, and baseline comorbid conditions to identify risk factors associated with pressure ulcers in critically ill adults. METHOD:A retrospective chart review was conducted on patients identified by weekly rounds from January 2010 through October 2010 to determine the prevalence of pressure ulcers. Variables were analyzed via bivariate analysis and logistic regression for unit-acquired pressure ulcers. RESULTS:Data on 345 patients with 436 intensive care admissions were reviewed. Variables were significant in each model category at P < .05. In the regression analysis of first admission only (n = 306), the model was significant (P < .001) and yielded correct classification of 86.3% of patients. For all intensive care admissions (n = 391), the model was significant (P < .001) and yielded correct classification of 83.9% of patients. In both models, 4 of the same variables were significant: any transport off the unit, number of days to bed change, systolic blood pressure less than 90 mm Hg, and use of more than 1 vasopressor. History of pulmonary disease and presence of a feeding tube were also significant in regression analyses. CONCLUSIONS:Several variables within the model of pressure, oxygenation, and perfusion were significantly associated with development of pressure ulcers. 10.4037/ajcc2016840
    A Prospective, Descriptive Study to Determine the Rate and Characteristics of and Risk Factors for the Development of Medical Device-related Pressure Ulcers in Intensive Care Units. Hanonu Seval,Karadag Ayise Ostomy/wound management Pressure ulcers do not develop only in areas with bony prominences; they can develop in any tissue under pressure, including pressure exerted by medical devices. A prospective, descriptive study was conducted from December 15, 2013 to March 25, 2014 to determine the prevalence, risk factors, and characteristics of medical device-related hospitalacquired pressure ulcers (MDR HAPUs) among all patients (N = 175) in 5 adult intensive care units (ICUs) in a university hospital in Turkey. The previously established point prevalence of hospital-acquired pressure ulcers (HAPUs) in these ICUs was 15%. Patients were evaluated in the first 24 hours after admission and observed 6 times thereafter in intervals of 48 hours. Demographic (eg, age, gender, body mass index) and medical device-related pressure ulcer data (eg, location, device type, stage), and Braden Scale scores were collected and analyzed; frequencies and percentages were calculated and Mann-Whitney U Test, t-test, and odds ratios were applied. Twenty-seven (27) patients (15.4%) developed nonMDR HAPUs and 70 (40.0%) developed MDR HAPUs. MDR HAPUs occurred most frequently (45.0%) in patients with an endotracheal tube. The most frequent type (42.6%) was Stage II. The highest rates of MDR HAPUs were observed among internal medicine ICU patients (OR 7.041), patients who also had a nonMDR HAPU (OR 6.6), patients in the high Braden risk score group (OR 1.8), or patients who received enteral feeding (OR 2.12). Because of the high rate of MDR HAPUs noted, policies and procedures aimed at preventing medical device-related pressure ulcers are needed.
    Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study. Smith Isabelle L,Brown Sarah,McGinnis Elizabeth,Briggs Michelle,Coleman Susanne,Dealey Carol,Muir Delia,Nelson E Andrea,Stevenson Rebecca,Stubbs Nikki,Wilson Lyn,Brown Julia M,Nixon Jane BMJ open OBJECTIVE:To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. DESIGN:Multicentre prospective cohort study. SETTING:UK hospital and community settings. PARTICIPANTS INCLUSION:Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). EXCLUSION:Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. FOLLOW-UP:Twice weekly for 30 days. PRIMARY AND SECONDARY OUTCOME MEASURES:Development and time to development of one or more category ≥2 PUs. RESULTS:Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). CONCLUSIONS:This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development. 10.1136/bmjopen-2016-013623
    Identification of Risk Factors for the Development of Pressure Ulcers Despite Standard Screening Methodology and Prophylaxis in Trauma Patients. Raff Lauren A,Waller Holly,Griffin Russell L,Kerby Jeffrey D,Bosarge Patrick L Advances in skin & wound care PURPOSE:To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients. TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES/OUTCOMES:After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients. ABSTRACT: OBJECTIVE:Pressure ulceration prevention has been emphasized  over the past several years in inpatient hospital settings with  subsequent decreases in the development of pressure ulcers (PrUs).  However, there remains a subset of trauma and burn patients  that develop PrUs despite standard screening methodology and  prophylaxis. This study determines the conditions that predict  development of pressure ulcers (PrUs) despite conventional  prophylaxis and screening.  METHODS:Demographic and PrU data were collected over a  5-year period from June 2008 to May 2013. Patients diagnosed  with PrUs upon arrival in the trauma bay were excluded from  analysis. An ordinal logistic regression of PrU stage was used to  estimate odds ratios (ORs) and associated 95% confidence intervals  (CIs) for the association between characteristics of interest and  odds of a PrU. A backward selection process was used to select the  most parsimonious model.  RESULTS:During the study period, 14,616 trauma patients were  admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63-9.01), mechanical ventilation (OR, 1.95; CI, 1.23-3.10) and age 40 to 64 (OR, 2.09; CI, 1.24-3.52) and age ≥ 65 (OR, 4.48; CI, 2.52-7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32-0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than -6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development.  CONCLUSIONS:Spinal injuries, older than age 40, and mechanical  ventilation predict the development of PrUs for a subset of  patients, despite conventional prophylaxis and screening. Advanced  prevention methods, such as low-air-loss mattresses for these patient  subgroups should be considered immediately upon identification  of these risk factors during the hospital course. 10.1097/01.ASW.0000484064.86180.18
    Pressure Relieving Support Surfaces for Pressure Ulcer Prevention (PRESSURE 2): Clinical and Health Economic Results of a Randomised Controlled Trial. Nixon Jane,Smith Isabelle L,Brown Sarah,McGinnis Elizabeth,Vargas-Palacios Armando,Nelson E Andrea,Coleman Susanne,Collier Howard,Fernandez Catherine,Gilberts Rachael,Henderson Valerie,Muir Delia,Stubbs Nikki,Walker Kay,Wilson Lyn,Hulme Claire EClinicalMedicine Background:Pressure ulcers (PUs) are complications of serious acute/chronic illness. Specialist mattresses used for prevention lack high quality effectiveness evidence. We aimed to compare clinical and cost effectiveness of 2 mattress types. Methods:Multicentre, Phase III, open, prospective, parallel group, randomised controlled trial in 42 UK secondary/community in-patient facilities.2029 high risk (acutely ill, bedfast/chairfast and/or Category 1 PU/pain at PU site) adult in-patients were randomised (1:1, allocation concealment, minimisation with random element) factors including: centre, PU status, facility and consent type. Interventions were alternating pressure mattresses (APMs) or high specification foam (HSF) for maximum treatment phase 60 days. Primary outcome was time to development of new PU Category ≥ 2 from randomisation to 30 day post-treatment follow-up in intention-to treat population. Trial registration: ISRCTN 01151335. Findings:Between August 2013 and November 2016, we randomised 2029 patients (1016 APMs: 1013 HSF) who developed 160(7.9%) PUs. There was insufficient evidence of a difference between groups for time to new PU Category ≥ 2 Fine and Gray Model Hazard Ratio HR = 0.76, 95%CI0.56-1.04); exact P = 0.0890; absolute difference 2%). There was a statistically significant difference in the , Fine and Gray model HR = 0.66, 95%CI, 0.46-0.93; exact P = 0.0176); 2.6% absolute difference). Economic analyses indicate that APM are cost-effective.There were no safety concerns. Interpretation:In high risk (acutely ill, bedfast/chairfast/Category 1 PU/ pain on a PU site) in-patients, we found insufficient evidence of a difference in time to PU development at 30-day final follow-up, which may be related to a low event rate affecting trial power. APMs conferred a small treatment phase benefit. Patient preference, low PU incidence and small group differences suggests the need for improved targeting of APMs with decision making informed by patient preference/comfort/rehabilitation needs and the presence of potentially modifiable risk factors such as being completely immobile, nutritional deficits, lacking capacity and/or altered skin/Category1 PU. 10.1016/j.eclinm.2019.07.018
    Pressure Ulcer and Nutrition. Saghaleini Seied Hadi,Dehghan Kasra,Shadvar Kamran,Sanaie Sarvin,Mahmoodpoor Ata,Ostadi Zohreh Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to health-care organizations. Accordingly, their prevention and management are highly important. Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. No laboratory test can exactly define an individual's nutritional status. Although serum albumin, prealbumin, transferrin, and retinol-binding protein as well as anthropometric measures such as height, weight, and body mass index and the other laboratory values may be suitable to establish the overall prognosis, still they might not well represent the nutritional status. Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, zinc, and Vitamins A, C, and E and also amino acids such as arginine and glutamine have been documented. Hydration plays a vital role in the preservation and repair of skin integrity. Dehydration disturbs cell metabolism and wound healing. Adequate fluid intake is necessary to support the blood flow to wounded tissues and to prevent additional breakdown of the skin. The main aim of the present article is to review the current evidence related to hydration and nutrition for bedsore prevention and management in adults. 10.4103/ijccm.IJCCM_277_17
    [Factors Predicting the Interface Pressure Related to Pressure Injury in Intensive Care Unit Patients]. Shine Ji Seon,Kim Soo Jin,Lee Ji Hyun,Yu Mi Journal of Korean Academy of Nursing PURPOSE:Interface pressure is a factor that contributes to the occurrence of pressure injuries. This study aimed to investigate interface pressure at common sites of pressure injury (occipital, gluteal and peritrochanteric areas), to explore the relationships among risk factors, skin condition and interface pressure, and to identify risk factors influencing interface pressure. METHODS:A total of 100 patients admitted to the intensive care unit were enrolled at a tertiary teaching hospital in Korea. Interface pressure was recorded by a scanning aid device (PalmQ). Patient data regarding age, pulmonary disease, Braden Scale score, body mass index, serum albumin, hemoglobin, mean blood pressure, body temperature, and oxygen saturation were included as risk factors. Data collected from July to September 2016 were analyzed using binary logistic regression. RESULTS:The mean interface pressure of the occipital, gluteal, and right and left peritrochanteric areas were 37.96 (±14.90), 41.15 (±16.04), 53.44 (±24.67), and 54.33 (±22.80) mmHg, respectively. Predictive factors for pressure injuries in the occipital area were age ≥70 years (OR 3.45, 95% confidence interval [CI]: 1.19~9.98), serum albumin deficit (OR 2.88, 95% CI: 1.00~8.26) and body temperature ≥36.5℃ (OR 3.12, 95% CI: 1.17~8.17); age ≥70 years (OR 2.81, 95% CI: 1.10~7.15) in the right peritrochanteric area; and body temperature ≥36.5℃ (OR 2.86, 95% CI: 1.17~6.98) in the left peritrochanteric area. CONCLUSION:Our findings suggest that old age, hypoalbuminemia, and high body temperature may be contributory factors to increasing interface pressure; therefore, careful assessment and nursing care of these patients are needed to prevent pressure injury. Further studies are needed to establish cutoff values of interface pressure for patients with pressure ulcers. 10.4040/jkan.2017.47.6.794
    Pressure Ulcers in the Intensive Care Unit: An Analysis of Skin Barrier Risk Factors. He Minjuan,Tang Amao,Ge Xuedi,Zheng Jie Advances in skin & wound care OBJECTIVE:The aim of this study was to determine whether skin barrier factors were associated with the common complication of pressure ulcers (PrUs) in intensive care unit (ICU) patients. It is unclear whether skin barrier factors influence the development of PrUs. PATIENT POPULATION:The sample was composed of 102 ICU patients (54 men, 48 women). The patients ranged in age from 23 to 88 years, with a mean age of 55.7 (SD, 19.1) years. METHODS:Demographic variables and the score for the Acute Physiology and Chronic Health Evaluation IV were recorded on admission. The Braden Scale assessment and measurements of the skin barrier factors were performed daily. Standard care for the prevention of PrUs was strictly administered, and PrUs that developed were evaluated according to the recommendations of the US National Pressure Ulcer Advisory Panel 2007 (Note: The authors used the 2007 recommendations at the time of their study.). Data were analyzed using descriptive statistics and logistic regression. RESULTS:The mean score for the Braden Scale was 11.2, and the incidence of PrUs was 31.4%. Lower moisture content of the stratum corneum and higher skin surface pH at the lower sacrum and hip were risk factors for PrUs, whereas scapular and heel skin barrier factors were not. CONCLUSION:Nursing strategies aimed at preventing PrUs should place added emphasis on the lower sacral and hip regions. 10.1097/01.ASW.0000494779.66288.c9
    What Factors Are Associated With the Development of Pressure Ulcers in a Medical Intensive Care Unit? Smit Inge,Harrison Lisa,Letzkus Lisa,Quatrara Beth Dimensions of critical care nursing : DCCN STATEMENT OF THE PROBLEM:Instruments used to determine the risk of pressure ulcer development are universally applied to adult patients. These instruments do not differentiate between intensive and acute care patients. BACKGROUND:Pressure ulcers contribute to negative outcomes such as increases in pain and discomfort, risk of infection, hospital length of stay and costs, and a decrease in quality of life. Appropriately identifying risk factors is paramount to implementing a targeted care plan to avoid pressure ulcer development as well as pinpointing appropriate treatments if an ulcer develops. OBJECTIVE:The purpose of this nursing research study was to identify factors associated with pressure ulcer development in a medical intensive care unit. METHODS:A 15-month retrospective chart review of patients with pressure ulcers in a medical intensive care unit was performed. Statistics were computed on demographics and variables of interest including: pressure ulcer stage, vasopressor infusion, oxygen requirement, comorbidities, primary diagnosis, length of stay, mortality, age, gender, weight, Braden scores, and albumin level. RESULTS:The characteristics of 76 patients who developed pressure ulcers were evaluated. An equal number of men (n = 38) and women (n = 38) were included. Forty-seven percent had a stage II pressure ulcer. The presence of hemodynamic support with vasopressor administration (P = .016) and the length of stay (P = .021) were noted as the most significant factors in pressure ulcer development in this study. CONCLUSIONS:Vasopressor use and length of stay are not factors that are accounted for in current pressure ulcer risk assessment instruments. The administration of vasopressor support and patient length of stay are potential contributory factors that need to be considered when assessing patients. Instruments specific to intensive care unit pressure ulcer risk stratification are warranted and should include the unique characteristics of a critically ill patient. 10.1097/DCC.0000000000000153
    Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors. Kim Chul-Hoon,Kim Myoung Soo,Kang Myung Ja,Kim Hyun Hee,Park Nam Jung,Jung Hyun Kyeong Journal of tissue viability PURPOSE:This study examined the incidence of oral mucosa pressure ulcers (PUs) in intensive care unit (ICU) patients and the relationship between biomechanical and physiological variables in onset of PUs. METHODS:A prospective observational descriptive study design was used. We recruited patients over 18 years of age with endotracheal tube (ETT) insertion in three ICUs in a tertiary hospital in Korea. We analysed 113 patient-days of data. Patient assessments and medical record reviews were conducted to gather biomechanical and physiological data. Fisher's exact tests and χ test and Spearman's rank correlations were used to compare data. RESULTS:The highest incidence of oral mucosa PUs occurred in lower oral mucosa (36.3%). There was a significant relationship between lower oral mucosa PU stage and bite-block or airway use (r = .20, p = .036), commercial ETT holder use (r = 0.19, p = .048), sedative use (r = -0.22, p = .022), and plasma protein (r = 0.20, p = .033). Upper oral mucosa PU stage was related to commercial ETT holder use (r = 0.19, p = .044), haemoglobin(r = 0.24, p = .011), haematocrit (r = 0.27, p = .004), and serum albumin (r = -0.24, p = .012). Stage was related to commercial ETT holder use in both sites (r = 0.28, p = .003), haematocrit (r = 0.19, p = .039), and serum albumin (r = -0.23, p = .015). CONCLUSION:Oral mucosa PUs developed more frequently and healed more quickly than general skin PUs. Taken together, these data indicate that biomechanical and haematological variables are risk factors associated with PU incidence should be considered in intensive care patients. 10.1016/j.jtv.2018.11.002
    Factors Affecting Wound Healing in Individuals With Pressure Ulcers: A Retrospective Study. Karahan Azize,AAbbasoğlu Aysel,Işık Sevcan Avcı,Çevik Banu,Saltan Çiğdem,Elbaş Nalan Özhan,Yalılı Ayşe Ostomy/wound management Owing to the number and severity of concomitant factors, pressure ulcers remain a significant problem. A retrospective study of data from adult patients with a pressure ulcer was conducted to identify factors that may affect their healing. Data from patients who were hospitalized between January 1, 2011, and December 31, 2015, in a private Turkish university hospital who had a Stage 2, Stage 3, Stage 4, or unstageable pressure ulcer that was assessed using the Bates-Jensen Wound Assessment Tool (BWAT) were abstracted. The following variables were examined: demographic characteristics (gender, age, hospital unit, duration of hospitalization), health status and disease data (vital signs, mobility, nutrition, diagnosis, chronic diseases, medication), laboratory values (albumin, hemoglobin, blood glucose), and pressure ulcer characteristics (stage, location, healing status, duration) and pressure ulcer risk status as determined by patient Braden Scale score. Seventy-eight (78) patient records were identified. Patient mean age was 70.8 ± 13.47 years, and length of hospitalization was on average 32.52 ± 27.2 days. Most ulcers (62; 79.5%) were Stage 2 and located in the sacral area (59; 75.6%). Thirty-four (34) patients (43.6%) were discharged and 44 (56.4%) died. At the time of discharge or death, 65.4% of the ulcers had not healed. Patients whose wounds were healed were significantly more likely to have higher hemoglobin and mean arterial pressure, better mobility, received oral nutrition, and discharged from the hospital than patients whose ulcers did not heal. The results suggest that these variables, including Braden Scale and BWAT scores, might be considered when developing a treatment plan of care. Additional studies examining risk factors for nonhealing pressure ulcers, including studies with large samples to facilitate multivariate analyses, are needed.
    [Incidence and risk factors associated with the development of pressure ulcers in an Italian general intensive care unit]. Lucchini Alberto,Elli Stefano,Bianchi Flora,Birleanu Nicoletta Doina,Zucchini Silvia,Ceccarelli Stefania,Tancredi Valeria,Zampieri Erica,Moretta Daniele,Bambi Stefano Assistenza infermieristica e ricerca : AIR . Incidence and risk factors associated with the development of pressure ulcers in an Italian general intensive care unit. INTRODUCTION:Pressure ulcers (PU) represent one of the most frequent adverse event in intensive care units (ICU). Critical patients are at higher risk of developing a PU, with an incidence between 3.3-39.3%. AIM:To assess the incidence and risk factors for developing PUs in a general ICU of an Italian University hospital. METHODS:Retrospective observational study on a sample of 122 patients admitted to a general intensive care unit, from January to December 2015, with a length of ICU stay > 5 days. PUs were stadied according to the National Pressure Ulcer Advisory Panel. RESULTS:One hundred and twenty two patients were enrolled. The incidence of PUs was 33%, and the incidence rate was 23 PUs for 1.000 days of ICU stay; 29% of PUs were of stage I, 56% of stage II, 8% stage III and 6% stage IV. PUs mainly affected the sacrum (21%) with a very low incidence in the heels (1.6%). Despite several factors were associated to the development of PUs (being female, Sequential Organ Failure Assessment, length of stay, mechanical ventilation > 72 hours, administration of dobutamine, Admission pO 2/FiO2 ratio, mean Braden during ICU stay and admission diagnosis) only ICU lenght of day remained statistically significant. CONCLUSIONS:The incidence of PUs is comparable to other recent studies. Many factors are potentially involved in the onset of PUs. Identifying these factors can help nurses to plan interventions to prevent their development. 10.1702/3080.30722
    Pressure Ulcer Risk Evaluation in Critical Patients: Clinical and Social Characteristics. de Azevedo Macena Mônica Suêla,da Costa Silva Rayanne Suely,Dias Fernandes Maria Isabel Da Conceição,de Almeida Medeiros Ana Beatriz,Batista Lúcio Kadyjina Daiane,de Carvalho Lira Ana Luisa Brandão The open nursing journal BACKGROUND:Pressure ulcers increase hospital stays and treatment costs due to their complications. Therefore, recognizing factors that contribute to pressure ulcer risk are important to patient safety. OBJECTIVE:To evaluate the association between the scores of the Waterlow, Braden, and Norton scales and clinical and social characteristics in critically ill patients. METHOD:A cross-sectional study of 78 patients in an adult intensive care unit of a university hospital in Northeastern Brazil was conducted from July to December 2015. Data included social and clinical information and the risk factors of the Braden, Norton and Waterlow scales. Data were analysed by the descriptive and inferential statistics. RESULTS:Most of the participants were female, adults and elderly people with brown skin colour, low education levels and insufficient income. Most of them showed a high risk for developing pressure ulcers using the three evaluated scales. Age, smoking status, diabetes and hypertension were associated with scores on the Waterlow, Braden and Norton scales. CONCLUSION:Age, use of the tobacco, diabetes and hypertension were associated with the risk of pressure ulcers in ICU patients. 10.2174/1874434601711010091
    Risk factors for pressure injuries among critical care patients: A systematic review. Alderden Jenny,Rondinelli June,Pepper Ginette,Cummins Mollie,Whitney JoAnne International journal of nursing studies OBJECTIVE:To identify risk factors independently predictive of pressure injury (also known as pressure ulcer) development among critical-care patients. DESIGN:We undertook a systematic review of primary research based on standardized criteria set forth by the Institute of Medicine. DATA SOURCES:We searched the following databases: CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses Global (ProQuest), PubMed (National Library of Medicine), and Scopus. There was no language restriction. METHOD:A research librarian coordinated the search strategy. Articles that potentially met inclusion criteria were screened by two investigators. Among the articles that met selection criteria, one investigator extracted data and a second investigator reviewed the data for accuracy. Based on a literature search, we developed a tool for assessing study quality using a combination of currently available tools and expert input. We used the method developed by Coleman et al. in 2014 to generate evidence tables and a summary narrative synthesis by domain and subdomain. RESULTS:Of 1753 abstracts reviewed, 158 were identified as potentially eligible and 18 fulfilled eligibility criteria. Five studies were classified as high quality, two were moderate quality, nine were low quality, and two were of very low quality. Age, mobility/activity, perfusion, and vasopressor infusion emerged as important risk factors for pressure injury development, whereas results for risk categories that are theoretically important, including nutrition, and skin/pressure injury status, were mixed. Methodological limitations across studies limited the generalizability of the results, and future research is needed, particularly to evaluate risk conferred by altered nutrition and skin/pressure injury status, and to further elucidate the effects of perfusion-related variables. CONCLUSIONS:Results underscore the importance of avoiding overinterpretation of a single study, and the importance of taking study quality into consideration when reviewing risk factors. Maximal pressure injury prevention efforts are particularly important among critical-care patients who are older, have altered mobility, experience poor perfusion, or who are receiving a vasopressor infusion. 10.1016/j.ijnurstu.2017.03.012
    Risk factors for pressure injury development in critically ill patients in the intensive care unit: a systematic review protocol. Coyer Fiona,Tayyib Nahla Systematic reviews BACKGROUND:Pressure injuries (PIs) create a significant burden in the health care system. Up to 49% of critically ill patients develop PIs. Identifying and understanding potential risk factors is essential to the provision of effective targeted prevention strategies to mitigate risk. The objectives of this review are to identify patient-centred clinical factors that may be associated with PI development in the adult intensive care environment and to determine the effect size of the relationship between identified factors and PI development in this unique population. METHOD/DESIGN:The review will follow the PRISMA reporting guidelines for systematic reviews. Electronic databases (Cochrane; PubMed/MEDLINE; CINAHL (EBSCOhost); Embase; Scopus; PsycINFO; Proquest; Networked Digital Library of Theses and Dissertations; Australian Digital Theses Program, Grey literature, Google scholar, and Clinical Trial Registries) will be systematically searched. A suite of search terms will identify articles that have examined the patient-centred risk factors for PI development in adult intensive care units. The search strategy will be designed to retrieve studies published since inception to 2016 in English language. Quality of the studies will be assessed by using an assessment framework designed to appraise quality in prognostic studies and methodological considerations in the analysis and publication of observational studies. Screening, study selection process, and data extraction will be undertaken by two independent reviewers. Disagreement will be resolved by discussion and, if required, a third independent reviewer. Clinical and methodological heterogeneity across studies will be assessed and, if possible, meta-analyses will be performed. DISCUSSION:The evidence synthesis arising from this review will identify person-centred risk factors that are associated with PI development among critically ill patients in intensive care. Findings from this review will demonstrate potential patient risk factors that may influence practice and research priorities to prevent PI development and improve the quality of care provided. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42016037690. 10.1186/s13643-017-0451-5
    Pressure Injury Risk Factors in Adult Critical Care Patients: A Review of the Literature. Cox Jill Ostomy/wound management Critically ill patients require complex care in a technologically sophisticated environment where they are highly vulnerable to pressure-related injuries. However, pressure injury (PI) development remains a multifactorial phenomenon in critically ill persons; true risk is both pervasive and elusive. The purpose of this comprehensive review of the empirical literature was to examine the risk factors associated with PIs among adult patients admitted to contemporary intensive care units (ICUs). Inclusion criteria stipulated publications were to be peer-reviewed, quantitative studies with a focus on pressure ulcer (PU) risk factors in adult critical care patients published between 2010 and 2016 in which statistical analysis involved multivariate analysis using PU development as the outcome variable. Studies not available in English, those in which the primary focus was on PU prevention or treatment, and those that focused solely on the use of PU risk assessment scales were excluded. A comprehensive review of the OVID and PubMed computerized databases using the search terms pressure ulcer, critical care, intensive care, and risk factors yielded 540 reports; 358 remained after duplicates were eliminated and 28 after the inclusion/exclusion criteria were applied. Following examination, 16 studies were suitable for inclusion. A total of 43 risk factors emerged. Of those, 7 were identified in 3 or more studies in multivariate regression analysis; these included age, prolonged ICU admission, diabetes mellitus, cardiovascular disease, hypotension, prolonged mechanical ventilation, and vasopressor administration. To facilitate results interpretation, risk factors from multivariate analyses were grouped in 6 broad categories: demographic/patient characteristics, comorbidities, intrinsic factors, iatrogenic/care factors, PI risk assessment scales, and severity of illness/mortality risk. The shared attribute of the 7 risk factors identified was they are all potentially nonmodifiable. Advancing the science regarding the pathogenesis of PI development is imperative when trying to better understand unavoidable pressure-related injuries. The need for large multisite studies and studies using large datasets capable of validating risk factors unique to this population persists. Additionally, the need for enhanced PI risk quantification for adult ICU patients remains.
    PRESSURE ULCER PREVENTION: FUNDAMENTALS FOR BEST PRACTICE. Collier Mark Acta medica Croatica : casopis Hravatske akademije medicinskih znanosti This introduction has highlighted both the complex nature of the aetiology of pressure ulcer development and the complexnature of the assessment process intended to identify those patients who are or might be at an enhanced risk of pressureulcer development. The latter statement assumes that all patients cared for in any healthcare setting are vulnerable topressure ulcer development. Whilst it is acknowledged that the use of a risk assessment tool can be important in an overallpressure ulcer prevention strategy, it is important that the limitations of these tools are acknowledged and that they are notan finite assessment in themselves and that they should be used by a practitioner with a fundamental breadth of relevantknowledge and an appreciation of the range of appropriate preventative equipment/techniques available and the role of themulti-disciplinary team in the prevention of all avoidable pressure ulcers.
    Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Mervis Joshua S,Phillips Tania J Journal of the American Academy of Dermatology Though preventable in most cases, pressure ulcers continue to pose a major burden to the individual and society, affecting ≤3 million adults annually in the United States alone. Despite increased national attention over the past 20 years, the prevalence of pressure ulcers has largely remained unchanged, while the associated costs of care continue to increase. Dermatologists can play a significant role in pressure ulcer prevention by becoming aware of at-risk populations and implementing suitable preventive strategies. Moreover, dermatologists should be able to recognize early changes that occur before skin breakdown and to properly identify and stage pressure ulcers to prevent delay of appropriate care. The aim of the first article in this continuing medical education series is to discuss the pathophysiology, risk factors, epidemiology, social and economic burdens, and clinical presentation of pressure ulcers. 10.1016/j.jaad.2018.12.069
    Risk factors for newly acquired pressure ulcer and the impact of nurse staffing on pressure ulcer incidence. Kim Jinhyun,Lee Jai-Yon,Lee Eunhee Journal of nursing management AIM:To analyse patient factors and nurse staffing-related issues involving hospital-acquired pressure ulcers in patients at two types of hospital. BACKGROUND:Hospital-acquired pressure ulcers are important for the safety of hospitalized patients. Hospital-acquired pressure ulcers not only cause health problems, but also pose an economic burden to patients. In addition to patient factors such as mobility and skin integrity, hospital factors such as nurse staffing can also affect the management of such patients. METHODS:This study is a retrospective review of patient data and analysis of factors related to hospital-acquired pressure ulcers using stratified Cox proportional hazards regression. RESULTS:A total of 53,923 patients were included. The incidence of hospital-acquired pressure ulcers was 0.98 per 1,000 days. Hospital-acquired pressure ulcers were affected by gender, age, previous falls, low oxygen levels, positioning and toilet use. When the levels of nurse staffing were determined as one of the hospital factors, the daily hours of patient care was increased thereby contributing to the reduced incidents of hospital-acquired pressure ulcers. CONCLUSION:Strategies for preventing hospital-acquired pressure ulcers should be based on the analysis of risk factors. IMPLICATIONS FOR NURSING MANAGEMENT:Most individual risk factors for hospital-acquired pressure ulcers identified cannot be modified easily in a short time. Nurse staffing should be set at adequate levels to prevent hospital-acquired pressure ulcers. 10.1111/jonm.12928
    Pressure ulcer summit 2018: An interdisciplinary approach to improve our understanding of the risk of pressure-induced tissue damage. Gould Lisa J,Bohn Gregory,Bryant Ruth,Paine Tim,Couch Kara,Cowan Linda,McFarland Frances,Simman Richard Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society Pressure ulcers (PrUs) affect approximately 2.5 million patients and account for 60,000 deaths annually. They are associated with an additional annual cost of $43,000 per related hospital stay and a total cost to the US health care system as high as $25 billion. Despite the implementation of national and international PrU prevention guidelines and toolkits, rates of facility-acquired PrU s and PrUs in people with spinal cord injury are still high. A new paradigm is needed that distinguishes between prevention and treatment research methods and includes not only the causative factors of pressure and tissue deformation but also patient-specific anatomical differences and the concomitant biological cellular processes, including reperfusion injury, toxic metabolites, ischemia, cell distortion, impaired lymphatic drainage, and impaired interstitial fluid flow that compound existing tissue damage. The purpose of this article is to summarize the highlights from the first annual Pressure Ulcer Summit held February 9-10, 2018 in Atlanta, Georgia (sponsored by the Association for the Advancement of Wound Care in partnership with multiple professional organizations). This international, interdisciplinary summit brought together key stakeholders in wound care and PrU prevention and management to highlight advances in pathophysiology of pressure-induced tissue damage; explore challenges in current terminologies, documentation, and data collection; describe innovations in clinical care; and identify research opportunities to advance the science of PrU prevention and management. 10.1111/wrr.12730
    Subepidermal moisture detection of pressure induced tissue damage on the trunk: The pressure ulcer detection study outcomes. Bates-Jensen Barbara M,McCreath Heather E,Patlan Anabel Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society We examined the relationship between subepidermal moisture measured using surface electrical capacitance and visual skin assessment of pressure ulcers at the trunk location (sacral, ischial tuberosities) in 417 nursing home residents residing in 19 facilities. Participants were on average older (mean age of 77 years), 58% were female, over half were ethnic minorities (29% African American, 12% Asian American, and 21% Hispanic), and at risk for pressure ulcers (mean score for Braden Scale for Predicting Pressure Ulcer Risk of 15.6). Concurrent visual assessments and subepidermal moisture were obtained at the sacrum and right and left ischium weekly for 16 weeks. Visual assessment was categorized as normal, erythema, stage 1 pressure ulcer, Deep Tissue Injury or stage 2+ pressure ulcer using the National Pressure Ulcer Advisory Panel 2009 classification system. Incidence of any skin damage was 52%. Subepidermal moisture was measured with a dermal phase meter where higher readings indicate greater moisture (range: 0-70 tissue dielectric constant), with values increasing significantly with the presence of skin damage. Elevated subepidermal moisture values co-occurred with concurrent skin damage in generalized multinomial logistic models (to control for repeated observations) at the sacrum, adjusting for age and risk. Higher subepidermal moisture values were associated with visual damage 1 week later using similar models. Threshold values for subepidermal moisture were compared to visual ratings to predict skin damage 1 week later. Subepidermal moisture of 39 tissue dielectric constant units predicted 41% of future skin damage while visual ratings predicted 27%. Thus, this method of detecting early skin damage holds promise for clinicians, especially as it is objective and equally valid for all groups of patients. 10.1111/wrr.12548
    Pressure Ulcer Risk in the Incontinent Patient: Analysis of Incontinence and Hospital-Acquired Pressure Ulcers From the International Pressure Ulcer Prevalence™ Survey. Lachenbruch Charlie,Ribble David,Emmons Kirsten,VanGilder Catherine Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society PURPOSE:To measure the prevalence of incontinence in the 2013-2014 International Pressure Ulcer Prevalence (IPUP) surveys and determine the relative risk of developing a facility-acquired pressure ulcers (FAPUs) by stage and by Braden Scale score groupings. DESIGN:The IPUP survey is an observational, cross-sectional cohort database designed to determine the frequency and severity of pressure ulcers in various populations. SUBJECTS AND SETTING:The survey includes acute care (91.4%), long-term acute care (1.7%), rehabilitation patients (1.7%) and long-term care residents (5.2%). Geographic distribution included 182,832 patients in the United States, 22,282 patients in Canada, and the rest of the world, primarily in Europe and the Middle East. METHODS:We analyzed data from the 2013 and 2014 IPUP surveys to better understand the relationship between incontinence and the frequency and severity of FAPUs. The IPUP survey is an annual voluntary survey of patients who are hospitalized or who reside in long-term care facilities. Data were collected over a 24-hour period within each participating facility. Data collection included limited demographics, presence and stage of pressure ulcers, and pressure ulcer risk assessment score (Braden Scale for Pressure Sore Risk, Braden Q, Norton, Waterlow, and others). In addition, data were collected on pertinent pressure ulcer risk factors including the number of linen layers, use of a pressure redistributing surface, adherence to repositioning schedule, and whether moisture management was provided in the last 24 hours. We aggregated data by urinary, urinary catheter, fecal, fecal management system, double (urinary and fecal), and ostomy incontinence category. If patients were managed by indwelling urinary catheter or fecal management systems, they were considered incontinent in this analysis. In order to analyze ulcers likely to be affected by incontinence, we defined a subset of ulcers as Relevant Pressure Ulcers, which are ulcers that are facility-acquired, non-device-related, and located in the pelvic region. RESULTS:We analyzed 176,689 patients based on data collected between 2013 and 2014. Slightly less than half (n = 83,800; 47%) of patients did not have incontinence, and 92,889 (53%) were deemed to be incontinent. The prevalence of pressure ulcers was 4.1% for continent patients and 16.3% for incontinent patients; the prevalence of FAPUs was 1.6% and 6.0%, respectively. The relative risk for PU development in incontinent patients was higher than predicted by the Braden Scale risk score. As wound severity increased, the odds ratios for pressure ulcer development for incontinent patients versus continent patients also increased, especially in patients with fecal incontinence. CONCLUSIONS:Incontinent patients had higher Braden Scale scores and higher overall and FAPU prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries. 10.1097/WON.0000000000000225
    Evaluation of physiological risk factors, oxidant-antioxidant imbalance, proteolytic and genetic variations of matrix metalloproteinase-9 in patients with pressure ulcer. Latifa Khlifi,Sondess Sahli,Hajer Graiet,Manel Ben-Hadj-Mohamed,Souhir Khelil,Nadia Bouzidi,Abir Jaballah,Salima Ferchichi,Abdelhedi Miled Scientific reports Pressure ulcer (PU) remains a common worldwide problem in all health care settings, it is synonymous with suffering. PU is a complex disease that is dependent on a number of interrelated factors. It involves multiple mechanisms such as physiological risk factors, chronic inflammation, oxidant-antioxidant imbalance and proteolytic attack on extracellular matrix by matrix metalloproteinases (MMP). Therefore, we propose that these wounds lead to molecular variations that can be detected by assessing biomarkers. In this study, we aimed to evaluate the major clinical elements and biological scars in Tunisian patients suffering from PU. Consistently, non-healing wound remains a challenging clinical problem. The complex challenges of the wound environment, involving nutrient deficiencies, bacterial infection, as well as the critical role played by inflammatory cells, should be considered because of their negative impact on wound healing. In addition, an imbalance between pro-oxidants and antioxidant systems seems to be more aggravated in patients with PU compared to healthy subjects. Of interest, this study provides further evidence to support a core role of the biological activity of MMP-9 in the pathogenesis of PU and indicates that the MMP9-1562 C/T (rs 3918242) functional polymorphism is associated with protection against this disease. 10.1038/srep29371
    Prolonged stay in the emergency department is an independent risk factor for hospital-acquired pressure ulcer. Han Dongkwan,Kang Bora,Kim Joonghee,Jo You Hwan,Lee Jae Hyuk,Hwang Ji Eun,Park Inwon,Jang Dong-Hyun International wound journal It is not easy to ensure optimal prevention of hospital-acquired pressure ulcer (HAPU) in crowded emergency departments (EDs). We hypothesised that a prolonged ED length of stay (LOS) is associated with an increased risk of HAPU. This is a single-centre observational study. Prospectively collected HAPU surveillance data were analysed. Adult (aged ≥20 years) patients admitted through the ED from April 1, 2013 to December 31, 2016 were included. The primary outcome was the development of HAPU within a month. Covariates included demographics, comorbidities, conditions at triage, initial laboratory results, primary ED diagnosis, critical ED interventions, and ED dispositions. The association between ED LOS and HAPU was modelled using logistic and extended Cox regression. A total of 48 641 admissions were analysed. The crude odds ratio (OR) and hazard ratio (HR) for HAPU were increased to 1.44 (95% CI, 1.20-1.72) and 1.21 (95% CI, 1.02-1.45), respectively, in ED LOS ≥24 hours relative to ED LOS <6 hours. In multivariable logistic regression, ED LOS ≥12 and ≥24 hours were associated with higher risk of HAPU, with ORs of 1.30 (95% CI, 1.05-1.60) and 1.80 (95% CI, 1.45-2.23) relative to ED LOS <6 hours, respectively. The extended Cox regression showed that the risk lasted up to a week, with HRs of 1.42 (95% CI, 1.07-1.88) and 1.92 (95% CI, 1.44-2.57) relative to ED LOS <6 hours, respectively. In conclusion, Prolonged ED LOS is independently associated with HAPU. Shorter ED LOS should be pursued as a goal in a multifaceted solution for HAPU. 10.1111/iwj.13266
    Risk Factors Associated With Pressure Ulcer Formation in Critically Ill Cardiac Surgery Patients: A Systematic Review. Rao Aditi D,Preston Ave M,Strauss Robyn,Stamm Rebecca,Zalman Demetra C Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society BACKGROUND:Cardiac surgery patients are among those most at risk for developing pressure ulcers (PUs), with a reported incidence as high as 29.5%. Although numerous studies documenting PU risk factors and prevention strategies exist, the availability of literature examining risk factors specific to the cardiac surgery population is limited. AIM:A systematic review was completed that aimed to identify the risk factors associated with PU development in critically ill, adult, cardiac surgery patients. METHODS:The MEDLINE, CINAHL, and Cochrane databases were searched. Studies that focused on PU risk factors in critical care, surgical intensive care, or cardiac surgery populations and used PU occurrences as an outcome variable were included in the review. FINDINGS:Twelve high-quality studies were retrieved and included in the review; they revealed 30 potential PU risk factors. Current evidence is limited in 2 important ways. First, the impact of intraoperative factors, such as cardiopulmonary bypass time or body temperature, appears to be underexplored. Second, a substantive discussion of the risk factors associated specifically with deep tissue injuries, a unique PU category, is absent. CONCLUSION:The relatively high PU incidence among cardiac surgery patients suggests that typical PU prevention methods are insufficient for this population. Targeted prevention measures must be developed and implemented. Completion of this task required identification of risk factors unique to this population. Specific risk factors likely to increase risk among cardiac surgery patients include prolonged exposure to pressure during long surgical procedures, vascular disease, and/or vasopressor use postoperatively. Additional research concerning risk factors specific to this population is urgently needed. 10.1097/WON.0000000000000224
    Microclimate: A critical review in the context of pressure ulcer prevention. Kottner Jan,Black Joyce,Call Evan,Gefen Amit,Santamaria Nick Clinical biomechanics (Bristol, Avon) Pressure ulcers are caused by sustained mechanical loading and deformation of the skin and subcutaneous layers between internal stiff anatomical structures and external surfaces or devices. In addition, the skin microclimate (temperature, humidity and airflow next to the skin surface) is an indirect pressure ulcer risk factor. Temperature and humidity affect the structure and function of the skin increasing or lowering possible damage thresholds for the skin and underlying soft tissues. From a pressure ulcer prevention research perspective, the effects of humidity and temperature next to the skin surface are inextricably linked to concurrent soft tissue deformation. Direct clinical evidence supporting the association between microclimate and pressure ulceration is sparse and of high risk of bias. Currently, it is recommended to keep the skin dry and cool and/or to allow recovery periods between phases of occlusion. The stratum corneum must be prevented from becoming overhydrated or from drying out but exact ranges of an acceptable microclimate are unknown. Therefore, vague terms like 'microclimate management' should be avoided but product and microclimate characteristics should be explicitly stated to allow an informed decision making. Pressure ulcer prevention interventions like repositioning, the use of special support surfaces, cushions, and prophylactic dressings are effective only if they reduce sustained deformations in soft tissues. This mode of action outweighs possible undesirable microclimate properties. As long as uncertainty exists efforts must be taken to use as less occlusive materials as possible. There seems to be individual intrinsic characteristics making patients more vulnerable to microclimate effects. 10.1016/j.clinbiomech.2018.09.010
    Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey. Kayser Susan A,VanGilder Catherine A,Lachenbruch Charlie International journal of nursing studies BACKGROUND:Prevalence of hospital-acquired pressure injuries has declined over time. However, it is unknown if this decline is consistent for different stages of pressure injuries. It is also unknown if risk factors differ between superficial (stage 1 and 2) and severe (stage 3, 4, deep tissue, and unstageable) pressure injuries. OBJECTIVE:To examine changes in prevalence of superficial and severe hospital-acquired pressure injuries from 2011 to 2016. To evaluate differences between risk factors associated with superficial versus severe hospital-acquired pressure injuries. DESIGN:Retrospective analysis of the 2011-2016 International Pressure Ulcer Prevalence™ data. SETTING:Acute care hospitals in the USA. PARTICIPANTS:216,626 patients had complete data. METHODS:Prevalence of all, superficial, and severe hospital-acquired pressure injuries was calculated annually from 2011 to 2016 and linear trendlines were generated. Two logistic regressions examined risk factors for superficial and severe hospital-acquired pressure injuries. RESULTS:Prevalence of superficial hospital-acquired pressure injuries declined significantly from 2011 to 2016. However, prevalence of severe pressure injuries did not show a reduction. Risk factors that significantly increased the risk of both superficial and severe pressure injuries were: increased age, male gender, unable to self-ambulate, all types of incontinence, additional linen layers, longer lengths of stay, and being in an intensive care unit. Body mass index (BMI) had a U-shaped relationship, where the likelihood of having either type of pressure injury was highest for low and high BMIs. CONCLUSIONS:A decline in superficial, but not severe, hospital-acquired pressure injuries suggests current prevention techniques might not adequately prevent severe pressure injuries. Generally, risk factors for superficial and severe pressure injuries were highly similar where all 14 of the risk factors were significant in both regression models. However, five risk factors in particular - ICU stay, presence of an ostomy, patient age, ambulatory status, and presence of a fecal management system - had substantially different effect sizes. 10.1016/j.ijnurstu.2018.09.003
    Risk factors for pressure ulcer development in Intensive Care Units: A systematic review. Lima Serrano M,González Méndez M I,Carrasco Cebollero F M,Lima Rodríguez J S Medicina intensiva INTRODUCTION:Pressure ulcers represent a significant problem for patients, professionals and health systems. Their reported incidence and prevalence are significant worldwide. Their character iatrogenic states that its appearance is preventable and its incidence is an indicator of scientific and technical quality both in primary care and specialized care. The aim of this review was to identify risk factors associated with the occurrence of pressure ulcers in critically ill patients. METHODOLOGY:The PRISMA Declaration recommendations have been followed and adapted to studies identifying risk factors. A qualitative systematic review of primary studies has been performed and a search was conducted of the PubMed, The Cochrane Library, Scopus and Web of Science databases. Methodological limitations in observational studies have been considered. RESULTS:From 200 references, 17 fulfilled the eligibility criteria. These studies included 19,363 patients admitted to intensive care units. Six studies were classified as high quality and 11 were classified as moderate quality. Risk factors that emerged as predictive of pressure ulcers development more frequently included age, length of ICU stay, diabetes, time of MAP <60-70mmHg, mechanical ventilation, length of mechanical ventilation, intermittent haemodialysis or continuous veno-venous haemofiltration therapy, vasopressor support, sedation and turning. CONCLUSIONS:There is no single factors which can explain the occurrence of pressure ulcers. Rather, it is an interplay of factors that increase the probability of its development. 10.1016/j.medin.2016.09.003
    Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study. Tayyib Nahla,Coyer Fiona,Lewis Peter International wound journal The purpose of this study was to identify pressure ulcer (PU) incidence and risk factors that are associated with PU development in patients in two adult intensive care units (ICU) in Saudi Arabia. A prospective cohort study design was used. A total of 84 participants were screened second daily basis until discharge or death, over a consecutive 30-day period, out of which 33 participants with new PUs were identified giving a cumulative hospital-acquired PU incidence of 39·3% (33/84 participants). The incidence of medical devices-related PUs was 8·3% (7/84). Age, length of stay in the ICU, history of cardiovascular disease and kidney disease, infrequent repositioning, time of operation, emergency admission, mechanical ventilation and lower Braden Scale scores independently predicted the development of a PU. According to binary logistic regression analyses, age, longer stay in ICU and infrequent repositioning were significant predictors of all stages of PUs, while the length of stay in the ICU and infrequent repositioning were associated with the development of stages II-IV PUs. In conclusion, PU incidence rate was higher than that reported in other international studies. This indicates that urgent attention is required for PU prevention strategies in this setting. 10.1111/iwj.12406
    Supplementing the Braden scale for pressure ulcer risk among medical inpatients: the contribution of self-reported symptoms and standard laboratory tests. Skogestad Ingrid Johansen,Martinsen Liv,Børsting Tove Elisabet,Granheim Tove Irene,Ludvigsen Eirin Sigurdssøn,Gay Caryl L,Lerdal Anners Journal of clinical nursing AIMS AND OBJECTIVES:To evaluate medical inpatients' symptom experience and selected laboratory blood results as indicators of their pressure ulcer risk as measured by the Braden scale. BACKGROUND:Pressure ulcers reduce quality of life and increase treatment costs. The prevalence of pressure ulcers is 6-23% in hospital populations, but literature suggests that most pressure ulcers are avoidable. DESIGN:Prospective, cross-sectional survey. METHODS:Three hundred and twenty-eight patients admitted to medical wards in an acute hospital in Oslo, Norway consented to participate. Data were collected on 10 days between 2012-2014 by registered nurses and nursing students. Pressure ulcer risk was assessed using the Braden scale, and scores <19 indicated pressure ulcer risk. Skin examinations were categorised as normal or stages I-IV using established definitions. Comorbidities were collected by self-report. Self-reported symptom occurrence and distress were measured with 15 items from the Memorial Symptom Assessment Scale, and pain was assessed using two numeric rating scales. Admission laboratory data were collected from medical records. RESULTS:Prevalence of pressure ulcers was 11·9, and 20·4% of patients were identified as being at risk for developing pressure ulcers. Multivariable analysis showed that pressure ulcer risk was positively associated with age ≥80 years, vomiting, severe pain at rest, urination problems, shortness of breath and low albumin and was negatively associated with nervousness. CONCLUSION:Our study indicates that using patient-reported symptoms and standard laboratory results as supplemental indicators of pressure ulcer risk may improve identification of vulnerable patients, but replication of these findings in other study samples is needed. RELEVANCE TO CLINICAL PRACTICE:Nurses play a key role in preventing pressure ulcers during hospitalisation. A better understanding of the underlying mechanisms may improve the quality of care. Knowledge about symptoms associated with pressure ulcer risk may contribute to a faster clinical judgment of patients at risk. 10.1111/jocn.13438
    Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study. de Almeida Medeiros Ana Beatriz,da Conceição Dias Fernandes Maria Isabel,de Sá Tinôco Jéssica Dantas,Cossi Marcelly Santos,de Oliveira Lopes Marcos Venicios,de Carvalho Lira Ana Luisa Brandão Intensive & critical care nursing OBJECTIVES:To evaluate the predictive power of risk factors for pressure ulcers in adult intensive care patients. METHOD:A retrospective case-control study was performed utilising a heterogeneous sample group allocated into a case group with pressure ulcers (n=90) and a control group without pressure ulcers (n=90). The analysis explored the predictive power of risk factors for pressure ulcers using a hierarchical logistic regression model. RESULTS:The risk factors that predicted pressure ulcers were friction (OR=5.97), previous history of pressure ulcers (OR=5.43), prolonged intensive care unit stay (OR=3.92), dehydration (OR=3.18), elevated skin temperature by 1-2°C (OR=3.12) and treatment of other comorbidities (OR=2.79). CONCLUSION:Adult intensive care patients have an increased risk of developing a pressure ulcer. These risk factors are regarded as strong predictors for pressure ulceration. This study advances nursing knowledge in that it investigates additional risk factors for the development of pressure ulcers and it identifies a set of factors that best predict their occurrence, which may contribute to the nurses' diagnostic reasoning in the intensive care unit. 10.1016/j.iccn.2017.09.007
    Dry skin and pressure ulcer risk: A multi-center cross-sectional prevalence study in German hospitals and nursing homes. Lechner Anna,Lahmann Nils,Neumann Konrad,Blume-Peytavi Ulrike,Kottner Jan International journal of nursing studies BACKGROUND:Pressure ulcers are a serious health problem in medical and nursing care. Therefore, effective prevention is crucial. Major pressure ulcer risk factors have been identified but the particular role of dry skin (xerosis cutis) is unclear. OBJECTIVES:To investigate possible associations between dry skin and pressure ulcers focusing on the sacrum/trochanter and at heel/ankle skin areas. DESIGN:Two multicenter cross-sectional studies. SETTINGS/PARTICIPANTS:In 2014 and 2015 thirty nursing homes and thirteen hospitals in Germany participated. In total 3837 participants were included. Mean age was 76.1 (SD 15.5) years. METHODS:Skin assessments and data collection were performed by trained nurses based on a standardized data collection form. Descriptive comparisons and multilevel logistic regressions predicting pressure ulcers at sacrum/trochanter and ankle/heel were conducted. RESULTS:The prevalence of skin dryness at the trunk was significantly higher for subjects with pressure ulcers category 2+ at the sacral area compared to without (39.0% vs. 24.4%, p=0.010). Adjusted to demographic variables, mobility and type of institution dry skin at the trunk was no longer associated with pressure ulceration (OR 1.11 (95% CI 0.62-2.00)). 71.9% of patients with heel/ankle pressure ulcers category 2+ were affected by dry skin at legs or feet, compared to 42.8% of subjects without pressure ulcers (p<0.001). In the adjusted analysis the OR was 1.85 (95% CI 0.83-4.14). CONCLUSIONS:Study results indicate that dry skin at the feet may be considered as a risk factor for heel pressure ulcer development. Skin dryness may be less important for sacral pressure ulcers. Therefore, the variable skin status should be better defined in future studies and pressure ulcer risk models. Results further support differences in pressure ulcer aetiologies between anatomical locations. 10.1016/j.ijnurstu.2017.05.011
    The use of a logistic regression model to develop a risk assessment of intraoperatively acquired pressure ulcer. Gao Ling,Yang Lina,Li Xiaoqin,Chen Jin,Du Juan,Bai Xiaoxia,Yang Xianjun Journal of clinical nursing AIMS AND OBJECTIVES:To screen the factors of intraoperatively acquired pressure ulcer and establish a new risk assessment model of intraoperatively acquired pressure ulcer. DESIGN:This is a prospective study. METHODS:A total of 1,963 patients who received neurosurgery, orthopaedics, paediatric surgery and cardiac surgery therapy in Sichuan Academy of Medical Science and Provincial People's Hospital in China from October 2015-October 2016 were enrolled in the study, and their clinical parameters were collected. Multivariable logistic regression analysis and decision tree analysis were used to analyse and screen the factors of intraoperatively acquired pressure ulcer and establish the risk assessment model of intraoperatively acquired pressure ulcer. RESULTS:The risk factors for intraoperatively acquired pressure ulcer included the application of external force during operation (β = 1.10, OR = 3.20), lean body mass (β = 1.08, OR = 2.95), time of operation ≥6 hr (β = 2.66, OR = 14.30), prone position operation (β = 1.13, OR = 3.10), cardiopulmonary bypass during operation (β = 1.72, OR = 5.59) and intraoperative blood loss (β = 0.67, OR = 1.95). The new risk assessment model showed that the AUC of ROC curve was 0.897 (p < .001). According to the maximum principle of Youden's index, the sensitivity, specificity and Youden's index J of the model were 0.81, 0.88 and 0.69, respectively, when the cut-off point was set at π = 0.025. CONCLUSIONS:A new and relatively reliable assessment model for intraoperatively acquired pressure ulcer is established. RELEVANCE TO CLINICAL PRACTICE:Pressure ulcers remain a challenge in clinical nursing. A new risk assessment model of pressure ulcers that is applicable to surgical patients is highly recommended. 10.1111/jocn.14491
    [Risk Factors of Medical Device-Related Pressure Ulcer in Intensive Care Units]. Koo MiJee,Sim YoungA,Kang InSoon Journal of Korean Academy of Nursing PURPOSE:The purpose of this study was to identify the characteristics of and risk factors for medical-device-related pressure ulcer (MDRPU) development in intensive care units. METHODS:A prospective cohort study design was used, and the participants were 253 adult patients who had stayed in medical and surgical intensive care units. Data were collected regarding the application of medical devices and MDRPU-related characteristics over a period of six months from June to November, 2017. Data were analyzed using independent t-test, χ²-test, Fisher's exact test, and binary logistic regression analysis with the SPSS 21.0 program. RESULTS:Among the 253 participants, MDRPUs occurred in 51 (19.8%) participants. The results of the logistic regression analysis showed that the risk factors for MDRPUs were the use of endotracheal tubes (OR=5.79, 95% CI: 1.66~20.20), having had surgery (OR=2.95, 95% CI: 1.11~7.77), being in a semi-coma/coma (OR=5.79, 95% CI: 1.04~32.05), and sedation (OR=5.54, 95% CI: 1.39~22.19). CONCLUSION:On the basis of the study results, it is effectively facilitated by nurses when they care for patients with MDRPUs in intensive care units and the results are expected to be of help in preventive education for MDRPU development as well as preparing the base data for intervention studies. 10.4040/jkan.2019.49.1.36
    The incidence of pressure ulcer in patients on mechanical ventilation andeffects of selected risk factors on pressure ulcer development. Karayurt Özgül,Akyol Özay,Kılıçaslan Necmiye,Akgün Nuray,Sargın Ümran,Kondakçı Melike,Ekinci Hanım,Sarı Neslihan Turkish journal of medical sciences BACKGROUND/AIM:This study aimed to determine the incidence of pressure ulcers in patients on mechanical ventilation and selected risk factors likely to play a role in pressure ulcer development. MATERIALS AND METHODS:The study included 110 patients recruited from an anesthesia critical care unit of a university hospital. Data were collected with a demographic and clinical characteristics form. The form was composed of questions about demographic characteristics and clinical features including diagnosis, duration of mechanical ventilation, general well-being, oxygenation, perfusion, and skin condition. RESULTS:The incidence of pressure ulcer was 15.5%. Duration of mechanical ventilation was longer and the body mass index was higher in patients developing pressure ulcers than in those without pressure ulcers. Additionally, 90.11% of patients with pressure ulcers had edema and 82.35% of patients with pressure ulcers received vasopressin. The patients with pressure ulcers had higher PH levels, lower PaO2 levels, higher PCO2 levels, lower SaO2 levels, and higher urine output. CONCLUSION:It can be recommended that nurses and other health professionals should be aware of factors playing a role in pressure ulcer development and should be able to conduct appropriate interventions to prevent pressure ulcers. 10.3906/sag-1504-139
    Therapeutic hypothermia and pressure ulcer risk in critically ill intensive care patients: A retrospective study. Ahtiala Maarit,Laitio Ruut,Soppi Esa Intensive & critical care nursing OBJECTIVE:To examine the role of therapeutic hypothermia in pressure ulcer development in critically ill patients. RESEARCH METHODOLOGY:Retrospective study in a mixed intensive care unit over 2010-2013. The incidences of pressure ulcers among patients treated with therapeutic hypothermia (n = 148) and the non-hypothermia patient population (n = 6197) were compared. RESULTS:Patients treated with hypothermia developed more pressure ulcers (25.0%) than the non-hypothermia group 6.3% (p < 0.001). More patients in the hypothermia group were rated as the high pressure ulcer risk group, as defined by the modified Jackson/Cubbin (mJ/C) risk score ≤29 than the rest of the patients. Among the therapeutic hypothermia patients more pressure ulcers tended to emerge in the lower risk group (mJ/C score ≥30) (p = 0.056). Intensive care mortality was higher in the hypothermia (24.3%) than the non-hypothermia group (9.3%, p < 0.0001). CONCLUSION:Patients treated with therapeutic hypothermia should be considered at high risk for pressure ulcer development and should be managed accordingly. The hypothermia may not as such increase the risk for pressure ulcers, but combined with the severity of the underlying illness, may be more likely. The pressure ulcer risk in this patient group cannot be reliably assessed by the Jackson/Cubbin risk scale. 10.1016/j.iccn.2018.02.008
    Relationship between pressure ulcer risk based on Norton Scale and on the "Eating/Drinking" need assessment. López María,Jiménez José María,Fernández Mercedes,Martín Belén,Cao María José,Castro María José Journal of nursing management AIM:To study the relationship between pressure ulcer risk evaluated by the Norton Scale and inadequate fulfilment of Need 2 (Eating/Drinking) from the 14-need classification designed by Virginia Henderson. BACKGROUND:Assessing nutritional status and skin condition to implement preventive measures are important nursing interventions. Our hospital's standard procedure requires recording Norton Scale and Henderson Eating/Drinking Assessment results. METHODS:This was a descriptive cross-sectional study, analysing case histories of 219 patients in medical/surgical wards for >24 hr with nursing care recorded in the GACELA Care computer application. Patient sociodemographic variables and evaluation concepts from the Norton Scale and Eating/Drinking were studied. RESULTS:A statistically significant relationship (p < 0.05; 95% CI: 0.61, 2.83) was seen between inadequate Eating/Drinking need fulfilment and increased pressure ulcer risk. Pressure ulcer risk was generally low in the sample, with mainly no or minimum risk (77.3%); the oldest age group had the highest risk. Self-care autonomy was the most frequently assessed item in Eating/Drinking (42%). CONCLUSIONS:A relationship was found between Norton Scale risk results and Eating/Drinking need assessment results. The greater the pressure ulcer risk, the more likely was inadequate need satisfaction (poor nutritional status). IMPLICATIONS:To help identify pressure ulcer risk, nurses should assess patients' eating independence. Safeguarding nutritional status and preventing pressure ulcers are nursing skills associated with quality nursing care. 10.1111/jonm.12655
    Skin status for predicting pressure ulcer development: A systematic review and meta-analyses. Shi Chunhu,Dumville Jo C,Cullum Nicky International journal of nursing studies BACKGROUND:People with altered skin status are conventionally considered to have a higher risk of developing new ulcers. However, the evidence underpinning this potentially prognostic relationship is unclear. OBJECTIVES:To systematically review the evidence for the prognostic association of skin status with pressure ulcer risk. METHODS:We performed a comprehensive electronic database search in February 2017 to identify longitudinal studies that considered skin status in multivariable analysis for predicting pressure ulcer risk in any population. Study selection was conducted by two reviewers independently. We collected data on the characteristics of studies, participants, skin status, and results of multivariable analyses of skin status-pressure ulcer incidence associations. We applied the Quality In Prognosis Studies tool to assess risk of bias. We conducted meta-analyses using STATA where data were available from multivariable analyses. We used the Grades of Recommendation Assessment, Development and Evaluation approach to assess the certainty of evidence generated from each meta-analysis. RESULTS:We included 41 studies (with 162,299 participants, and 7382 having new ulcers) that investigated 15 skin descriptors. Participants were predominantly hospitalised adults and long-term care residents (with a median age of 75.2 years). Studies had a median follow-up duration of 7.5 weeks. 61.0% (25/41) of studies were judged as being high risk of bias. 53.7% (22/41) of studies had small sample sizes. Subsequently, the certainty of evidence was rated as low or very low for all 13 meta-analyses that we conducted though all analyses showed statistically significant associations of specific skin descriptors-pressure ulcer incidence. People with non-blanchable erythema may have higher odds of developing pressure ulcers than those without (Odds Ratio 3.08, 95% Confidence Interval 2.26-4.20 if pressure ulcer preventive measures were not adjusted in multivariable analysis; 1.99, 1.76-2.25 if adjusted) (both low-certainty evidence). The evidence for other skin descriptors was judged as very low-certainty and their prognostic value is uncertain. CONCLUSIONS:There is low-certainty evidence that people with non-blanchable erythema may be more likely to develop new pressure ulcers than those without non-blanchable erythema. The evidence for the prognostic effects of other skin descriptors (e.g., history of pressure ulcer) is of very low-certainty. The findings support regular skin assessment and preventive action being taken in the presence of non-blanchable erythema. Given the millions at risk of ulceration and the widely recommended use of skin status as part of risk assessment there is a need for more, high quality confirmatory studies. 10.1016/j.ijnurstu.2018.07.003