The uptake of the international pressure ulcer/injury prevention and treatment guidelines in the scientific literature: A systematic analysis of two major citation databases

BackgroundThe European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance developed international Clinical Practice Guidelines of the prevention and treatment of pressure ulcers/injuries in 2009, 2014, and 2019. Despite substantial dissemination efforts, evidence about guideline dissemination and uptake in the international literature is lacking.AimThe aim of this review was to capture to the greatest detail possible the number of the citations of the three published Clinical Practice Guidelines.MethodsThe citation databases Web of Science and Scopus were searched for citations of the 2009, 2014 and 2019 Clinical Practice Guidelines including all derivative products including short versions and translations. Two separate search strategies were iteratively developed to ensure highest sensitivity.ResultsThe Cited Reference Search in Web of Science identified hundreds of different referencing formats with more than 2000 citing articles. The Scopus search revealed 250 different reference formats and more than 2000 citation counts. After publication there was a gradual increase of citations that peaks approximately after four years.ConclusionThe three Clinical Practice Guidelines including all derivate versions had a substantial uptake in the scientific literature. This supports the assumption that the guideline dissemination strategies were and are successful.     

地震救援作业人员健康危害预警系统构建

目的构建灾害救援作业人员健康危害预警系统,避免因决策指挥失误导致对救援作业人员的健康危害。方法通过现场调查、文献检索,应用层次分析法建立指标体系,通过“人-机-环-管理”系统分析法,构建救援作业人员健康危害预警系统框架。结果灾害救援作业危害评价体系一级指标为人体因素、设备因素、环境因素和管理因素,二级指标共13个,三级指标共34个;构建包括健康风险、环境危害、装备风险和管理风险4个数据库,分别在灾害救援前期、中末期、休整期可做出健康危害预警。结论通过定性定量评价,健康危害预警系统可对灾害救援作业人员做出早期健康危害预警,有利于救援作业效率的提升。     

The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment

AimThe purpose of this study was to examine the relationship of subepidermal moisture and early stage pressure injury by visual skin assessment in elderly Korean.MethodsTwenty-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.ResultsSubepidermal 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.ConclusionSubepidermal moisture would be used to predict early skin damage in clinical nursing field for the effective pressure injury prevention.     

Biomarkers for the early detection of pressure injury: A systematic review and meta-analysis

BackgroundPressure injury imposes a significant burden for patients and healthcare systems and the majority of pressure injuries are preventable. The early identification of pressure injury is critical for its prevention. As an objective measure, biomarkers have preliminarily shown the potential to identify individuals at risk for developing pressure injury before it is visually observed to occur. However, these results have not been synthesized.ObjectiveTo assess and synthesise the predictive effect of different biomarkers in the early detection of pressure injury formation.DesignA systematic review and meta-analysis.Data sourcesPubMed, EMBASE, CINAHL Complete and the Cochrane Library were comprehensively searched for articles up to June 2021. No restrictions were applied to study design type, language, country, race or date of publication.Review methodsTwo reviewers independently extracted data from all original eligible studies using a specified data extraction form, resolved disagreements through discussion and the involvement of an additional reviewer. Methodological quality of all included studies was independently appraised by two authors with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and the Newcastle-Ottawa Quality Assessment Scale (NOS). Heterogeneity of each study was estimated using the I² statistic, and the data was synthesized using StataSE15.ResultsEight observational studies involving 10595 participants were included. The overall pooled area under curve (AUC) and the 95% confidence intervals (CIs) of Serum albumin (Alb) was 0.66(0.62–0.70), and the Serum haemoglobin (Hb) was 0.67(0.60–0.74). The AUC and 95% CI of C-reactive protein (CRP) was 0.62(0.50–0.74), Braden score was 0.56 (0.429–0.691), Waterlow score was 0.729(0.654–0.803), Alb with Waterlow was 0.741(0.694–0.787), and the combination of Hb, CRP, Alb, Age and Gender was 0.79(0.682–0.898). Besides, the chemokine interferon-γ-induced protein of 10kd/CXCL10, cytokine interferon-α, tumor necrosis factor-alpha (TNF-α), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-15 (IL-15) and combination of creatine kinase (CK), myoglobin (Mb), heart-type fatty acid binding protein (H-FABP) and CRP may prove potential for detecting pressure injury.ConclusionThe findings suggest the combination of Hb, CRP, Alb, Age and Gender is superior to other biomarkers. However, the predictive effect of biomarkers needs to be confirmed by more researches and patient-level data.     

Skin blood flow dynamics and its role in pressure ulcers

Pressure ulcers are a significant healthcare problem affecting the quality of life in wheelchair bounded or bed-ridden people and are a major cost to the healthcare system. Various assessment tools such as the Braden scale have been developed to quantify the risk level of pressure ulcers. These tools have provided an initial guideline on preventing pressure ulcers while additional assessments are needed to improve the outcomes of pressure ulcer prevention. Skin blood flow function that determines the ability of the skin in response to ischemic stress has been proposed to be a good indicator for identifying people at risk of pressure ulcers. Wavelet spectral and nonlinear complexity analyses have been performed to investigate the influences of the metabolic, neurogenic and myogenic activities on microvascular regulation in people with various pathological conditions. These findings have contributed to the understanding of the role of ischemia and viability on the development of pressure ulcers. The purpose of the present review is to provide an introduction of the basic concepts and approaches for the analysis of skin blood flow oscillations, and present an overview of the research results obtained so far. We hope this information may contribute to the development of better clinical guidelines for the prevention of pressure ulcers.     

Validity and reliability of the Turkish version of the pressure injury knowledge assessment tool 2.0

AimThe aim of this study was to develop a Turkish version of the Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT 2.0) and determine its validity and reliability.Materials and MethodsThis was a cross-cultural adaptation and validation study. The study sample included a total of 451 participants (232 nurses and 219 nursing students). The validity of the Turkish version of the PUKAT 2.0 was evaluated with linguistic validity, content validity, item validity (item difficulty, discriminating index), and construct validity (known-groups technique) analyses. The reliability of the tool was evaluated by conducting a test–retest analysis.ResultsContent validity index (CVI) for the items (Item-CVI) ranged from 0.83 to 1.00 and the CVI for the scale (Scale-CVI) was 0.95. The difficulty index for 21 items ranged from 0.10 to 0.63. Four items were found to be too difficult. Item discriminating index values ranged from 0.00 to 0.61. The overall intraclass correlation coefficient (ICC) was found to be 0.80.ConclusionThe Turkish version of the Pressure Injury Knowledge Assessment Tool 2.0 (PIKAT 2.0-Tr) is supported by acceptable psychometric properties and can be used to evaluate the knowledge of nurses and nursing students in Turkey about the prevention of PI.     

Tissue temperature,flux and oxygen of sacral and trochanteric area under pressure of healthy subjects: A quasi-experimental study

AimTo evaluate the changes that take place in the perfusion, oxygenation and local temperature of the skin of the sacrum and trochanter when subjected to direct pressure for 2 h.MethodsQuasi-experimental study in the preclinical phase with healthy subjects acting as their own controls (intrasubject control). The outcome variables were measured with a laser Doppler system (local temperature and oxygenation) and by near-infrared spectroscopy (perfusion). The pressure exerted was measured with a capacitive pressure sensor. No more than one week elapsed between the sacrum and trochanter measurements.ResultsThe study sample consisted of 18 persons. The comparative analysis of the fluctuations in the parameters measured on the skin of the trochanters and sacrum, according to the time elapsed, revealed a statistically significant increase in temperature and in the pressure exerted. On the other hand, the changes in capillary blood flow and in SaO2 were not statistically significant.ConclusionOur study results show that changes found in terms of temperature and pressure should be taking into account when planning personalised repositioning to patients according to biomechanical and biological situations that vary between anatomical areas. In future research, the changes reported could be evaluated in patients with risk factors for the development of pressure ulcers, thus facilitating the introduction of more personalised planning in the care and prevention of these injuries.     

The effect of pH-compatible cleansing cloths on skin pH and the development of pressure ulcers

AimSkin care plays an important role in the prevention of the development of pressure ulcers. The aim of this study was to determine the effect of skincare with a body pH-compatible cleansing cloth on the development time of pressure ulcers and on skin pH.MethodsThis experimental research was conducted with 156 patients hospitalized in intensive care clinics of a state hospital between September 2019 and 2020. The sample was calculated with a power of 80% and a significance level of 0.05 (α error) and as a result, 78 elderly patients formed the intervention group and another 78 elderly patients made up the control group. Data were collected using the Elderly Information Form, Braden Risk Assessment Scale, Pressure Ulcer Staging Tool and Skin pH Measurement Form. The pre- and post-care skin pH of both groups was measured with a skin pH meter. P < 0.05 was considered statistically significant.ResultsThe average development time for pressure ulcers was 14.9 days in the control group, 18.9 days in the intervention group and the difference was not statistically significant (p > 0.05). Skin pH decreased in the intervention group after the skin care routine was applied, whereas it increased in the control group.ConclusionIt can be said that care of one's skin with a body pH-compatible cleansing cloth has a positive effect on the development time of pressure ulcers and also positively changes the skin pH to acidic.     

A comparison of air-cell and gel surgical table pads and an evaluation of the influence of pressure distribution and other factors on pressure injury prevention

Guidelines for pressure injury prevention consider the use of pressure-redistributing pads to prevent tissue deformation. However, limited research exists to assess the pressure distribution provided by the operating tables and the effectiveness of pressure-redistributing pads in preventing pressure injuries. In this study, we compared the pressure distribution properties of two surgical table pads and identified parameters influencing pressure injury outcomes after a lengthy surgical procedure. Twenty-seven patients undergoing left ventricular assist device implantation surgery participated in the study. Participants were randomly assigned to use either an air cell-based pad or a gel pad. Interface pressure was recorded during the surgery. We analyzed the effect of surgical table pad type, interface pressure distribution and pressure injury outcomes and analyzed what characteristics of the patients and the interface pressure are most influential for the development of pressure injuries. Comparing the interface pressure parameters between the air-cell group and the gel group, only the peak pressure index x time was significantly different (p < 0.05). We used univariate logistic regression analysis to identify significant predictors for the pressure injury outcome. The support surface was not significant. And, among patient characteristics, only age and BMI were significant (p ≤ 0.05). Among the interface pressure parameters, pressure density maxima, peak pressure index x time, and coefficient of variation were significant for pressure injury outcome (p ≤ 0.05). Peak pressure index, average pressure, and the surgery length were not statistically significant for pressure injury outcomes.     

Determination of medical device-related pressure injury in COVID-19 patients: A prospective descriptive study

BackgroundCOVID-19 patients are at risk for the development of pressure injuries (PI).AimThe aim of this study was to determine the incidence of medical device-related pressure injury (MDRPI) in patients treated in the COVID-19 Intensive Care Unit (ICU)s.MethodsThe sample of the study consisted of 132 patients, and each with a maximum follow-up of 7 days. Data were collected in the COVID-19 ICU of a university hospital between January and May 2021 by using a Patient Characteristics Form, the MDRPI Follow-up Form, the Braden Pressure Ulcer Risk Assessment Scale, and the Pressure Ulcer Staging Form.ResultsOf the patients, 59.1% (n = 78) developed at least one MDRPI. MRDPI was observed in those with a mean age of 65.45 ± 2.462 years who were invasively ventilated (51.3%), enterally fed (46.2%), placed in the prone position (78.2%), and had a Braden score ≤12 (50%). The most common medical devices that caused MDRPIs included endotracheal tube (ET) (31.2% n = 44), non-invasive mechanical ventilation (NIVM) (23.4% n = 33), nasal high-flow (11.3% n = 16), nasogastric tube (10.6% n = 15), the ET connection (8.5% n = 12), respectively. The most common sites for pressure injuries were the nose (28.8% n = 34), mouth (25.8% n = 34), ear (12.9% n = 17), lip (9.1% n = 12), and cheek (8.3% n = 11). The most common gradings of MDRPIs were stage 2 (28.8% n = 38), stage 1 (19.7% n = 26), stage 3 (9.1% n = 12) mucous membrane injuries (12.9% n = 17) and suspected deep tissue injuries (9.1% n = 12), respectively. The time to PI was 3 days (25.7% n = 36).ConclusionsMDRPI was common among COVID-19 patients. It was found that the most common cause of pressure injury was ventilators, and PI developed in the mouth and lip sites most frequently in patients in prone position, stage 2 and suspected deep tissue damage was the most common grade. It is important to evaluate the skin in contact with medical devices in COVID-19 patients and to take the necessary interventions to prevent PI.     

Skin self-management of community-dwelling patients with spinal cord injury: A cross-sectional study

Backgroundcommunity-acquired pressure injury is one of the most common and troublesome complications of discharged patients with spinal cord injury. Previous studies have shown that pressure injury can not only increase the financial burden and care burden of patients, but also seriously affect their quality of life.AimTo evaluate the skin self-management of community-dwelling patients with spinal cord injury and to explore the related independent influencing factors.MethodsThis was a cross-sectional survey study. A convenience sample of 110 community-dwelling patients with spinal cord injury recruited from three rehabilitation centers in Guangzhou and Chengdu in China completed the survey from September 2020 to June 2021. They were asked about their demographic data, skin self-management, knowledge about skin self-management, attitude to skin self-management, self-efficacy, and functional independence. Univariate analysis and multiple linear regression were performed to isolate the most important relationships.ResultsThe skin self-management of community-dwelling patients with spinal cord injury was relatively low, and they also performed poorly in the three categories of: skin check, preventing pressure ulcer, and preventing wounds. Skin self-management was found to be most often associated with level of knowledge about skin self-management, higher reimbursement and self-efficacy.ConclusionCommunity-dwelling patients with spinal cord injury with lower level of knowledge about skin self-management, with lower self-efficacy, and those with higher reimbursement have worse skin self-management.     

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial

AimSub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS.Materials and methodsThis pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes.ResultsOf 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing.ConclusionsMost feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.     

Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019

Aim

The European Pressure Ulcer Advisory Panel, the Pan Pacific Pressure Injury Alliance, and the National Pressure Ulcer Advisory Panel are updating the ‘Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline’ (CPG) in 2019. The aim of this contribution is to summarize and to discuss the guideline development protocol for the 2019 update.

Development and preliminary validation of a tool measuring concordance and belief about performing pressure-relieving activities for pressure ulcer prevention in spinal cord injury

ObjectiveTo develop and examine the reliability, and validity of a questionnaire measuring concordance for performing pressure-relief for pressure ulcer (PrU) prevention in people with Spinal Cord Injury (SCI).MethodsPhase I included item development, content and face validity testing. In phase II, the questionnaire was evaluated for preliminary acceptability, reliability and validity among 48 wheelchair users with SCI.ResultsThirty-seven items were initially explored. Item and factor analysis resulted in a final 26-item questionnaire with four factors reflecting concordance, perceived benefits, perceived negative consequences, and personal practical barriers to performing pressure-relief activities. The internal consistency reliability for four domains were very good (Cronbach's α = 0.75-.89). Pearson correlation coefficient on a test-retest of the same subjects yielded significant correlations in concordance (r² = 0.91, p = .005), perceived benefit (r² = 0.71, p < .04), perceived negative consequences (r² = 0.98, p < .0001), personal barriers (r² = 0.93, p= .002). Participants with higher levels of concordance reported a greater amount of pressure-relieving performed. Individuals viewing PrU as a threatening illness were associated with higher scores of concordance and tended to report a greater amount of pressure-relieving performance which provides evidence of criterion related validity.ConclusionThe new questionnaire demonstrated good preliminary reliability and validity in people with SCI. Further evaluation is necessary to confirm these findings using larger samples with follow-up data for predictive validity. Such a questionnaire could be used by clinicians to identify high risk of patients and to design individualised education programme for PrU prevention.     

Influencing factors of pressure injury healing in an acute care setting: A retrospective cohort study

AimThis study aimed to investigate the factors that influence healing during acute care hospitalization by examining the differences in pressure injury (PI) status between admission and discharge.Material and methodsA total of 371 patients who met the study's inclusion criteria were divided into two groups (aggravated or improved) based on the PI status observed at admission and discharge. We used bivariate analyses to compare demographics and clinical factors associated with wound severity and aggravation/improvement of wound condition. Using multiple logistic regression, we identified and examined independent predictors for significant association with aggravation/improvement of the wound status.ResultsThe prevalence rate of PI at acute hospital admission was 12.5%. By the time of discharge, only 5.4% of PI patients had improved PI, whereas 12.6% had aggravated PI. The significant aggravating factors of PI during acute care hospitalization were the patient's consciousness level, use of foley catheter, creatinine level, and Braden Scale scores (p < .05). Residential place prior to admission were found to be associated with the healing.ConclusionsNurses providing prophylactic management require close attention to patients who are admitted from long-term facilities to prevent aggravation of PI during acute care hospitalization.     

负压封闭引流(VSD)技术在NPUAP 3、4期压力性损伤患者中的应用及护理

目的探讨负压封闭引流(vacuum sealing drainage,VSD)技术对国际压疮防治顾问学会(national pressure ul-cer advisory painel,NPUAP)3、4期压力性损伤患者的持效及护理体会。方法选取2017年1月一2018年12月大连大学附属中山医院收治的14例NPUAP 3、4期压力性损伤患者,住院后创面行坏死组织清创术,术后采用VSD对创面进行封闭引流,同时给予抗感染、营养、对症、支持等治疗及护理。结果3、4期压力性损伤患者在VSD治疗后的创面面积为(39.11±9.57)cm^2,较治疗前的(137.9±32.24)cm^2明显缩小,差异有统计学意义(P=0.0036)。VSD还能够显著促进创面肉芽组织的生长,刺激毛细血管增生,加快创面愈合速度。结论采用VSD治疗3、4期压力性损伤可显著缩小创面,促使创面血管再生,加快肉芽姐织生长,促进创面愈合,临床疗效明显,值得临床大力推广应用。