Pressure injury prevalence in Australian & New Zealand hospitals: Systematic review protocol

BackgroundPressure injuries are a global, largely preventable problem. Pressure injuries, and their complications are associated with higher morbidity and mortality rates and place a financial strain on health care systems. Pressure injury prevalence studies are conducted regularly within hospitals in Australia and New Zealand, however there is no consensus on the prevalence rate of pressure injuries in these settings. This lack of data synthesis limits the ability of healthcare organisations to evaluate pressure injury practice against national and international benchmarks.AimTo synthesise data on the prevalence of pressure injuries within Australian and New Zealand Hospitals.Method and analysisA systematic review of published and grey literature will be undertaken using a two-phase search. Studies will be assessed for inclusion and the Joanna Briggs Institute Appraisal Checklist for Studies Reporting Prevalence Data will be used to assess source quality by multiple authors. Data extraction will be undertaken independently by two authors. Data synthesis will be completed using STATA software and the METAPROP command and where numerical synthesis is not possible, data will be summarised in narrative form. The overall prevalence of pressure injuries will be quantified, and a narrative synthesis of additional outcomes will be undertaken.DiscussionInclusion of both published and grey literature in this review will enable a precise estimate of pressure injury prevalence rates in these settings to be determined. A narrative review of the methodology used in included studies will also be completed with recommendations made on best practices to promote accurate data collection.     

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BackgroundPressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.ObjectivesThe objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.MethodsA prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1–18; period 2, weeks 19–28; and period 3, weeks 29–52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.ResultsOver the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20–0.97, p = 0.0126).ConclusionsWe found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.     

Pressure ulcer prevalence and incidence in intensive care patients: a literature review

Background: Pressure ulcers remain a common health problem worldwide within the different health‐care settings, especially in intensive care settings. Aims: The aims of this were to systematically assess the recent prevalence and incidence of pressure ulcers in intensive care patients (2000–2005), the factors related to pressure ulcer prevalence and incidence and the methodological rigour of studies about pressure ulcer prevalence and incidence in intensive care patients. Methods: The research design involved a review of literature for the period of 2000 to 2005, focused on the prevalence and incidence of pressure ulcers in intensive care patients. Results: The analysis of published papers revealed variations in pressure ulcer prevalence in intensive care settings ranging from 4% in Denmark to 49% in Germany, while incidence ranged from 38% to 124%. There was a wide variation in the prevalence and incidence of pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in the prevention and treatment of pressure ulcers which needs to be addressed. Conclusion: Further research is needed regarding the effectiveness of nursing care on pressure ulcer development and into treatments that may successfully prevent their occurrence in intensive care patients.     

Efficacy of a heel offloading boot in reducing heel pressure injuries in patients in Australian intensive care units: A single-blinded randomised controlled trial

ObjectivesTo compare time to incidence, extent of incidence and severity of heel pressure injury with a heel off-loading boot (intervention) or pillows (control).Research methodology/designMulti-centre, single-blinded randomised controlled trial of 394 critically ill patients. Patients were randomised to the intervention or control for heel offloading.SettingThree hospital intensive care units; two in greater Sydney, Australia and one in regional New South Wales, Australia.Main outcome measuresTime to intensive care unit-acquired pressure injury in heels of patients without pre-existing heel pressure injury within 28 days from intensive care unit admission. Secondary outcomes: incidence of heel pressure injury within 28 days of intensive care unit admission; severity of intensive care unit-acquired heel pressure injuries; occurrence of plantar contractures (a change in ankle dorsiflexion of 5° or greater) within 28 days of admission.ResultsWithin 28 days of admission, one pressure injury was recorded in the intervention group and 11 in the control group. Hazard of pressure injury incidence within 28 days of admission was significantly lower (p = 0.0239) in heels assigned to the intervention (hazard ratio 0.0896 [95% CI 0.0110, 0.727]). Odds of pressure injury incidence within 28 days of admission were significantly lower (p = 0.0261) in the intervention group (odds ratio 0.0883 [95% CI 0.0104, 0.749]). The pressure injury recorded in the intervention group was superficial (stage 1) whereas those recorded in the control group were more severe (stage 2 to 4).ConclusionThe heel-offloading boot used in this study significantly reduced heel pressure injury occurrence compared with heel offloading using pillows.     

Exploring medical device-related pressure injuries in a single intensive care setting: A longitudinal point prevalence study

ObjectivesTo report longitudinal prevalence rates of device-related pressure injuries in critically ill adult patients in the intensive care unit and to explore the patient characteristics associated with the development of device related pressure injuries.Research designA prospective observational design where observations of patients’ skin integrity were conducted on one day each week for 52 weeks.SettingThe study was conducted in the 36-bed intensive care unit of a major metropolitan tertiary referral hospital in Queensland, Australia. The sample included all patients aged 18 years or older admitted to the intensive care unit before midnight on the day preceding the observation, with a medical device in situ.Main outcome measuresThe primary outcome measure was device related pressure injuries identified at the weekly observations and defined as a pressure injury found on the skin or mucous membrane with a history of medical device in use at the location of the injury. Patient demographic and clinical characteristics were recorded.ResultsOver the study period, 11.3% (71/631) of patients developed at least one hospital-acquired DRPI.The most common devices associated with injury were nasogastric/nasojejunal tubes (41%) and endotracheal tubes (27%). Significant predictors of device related pressure injuries were the total number of devices (OR 1.230, 95% CI 1.09–1.38, p < 0.001), the length of time in the ICU (OR 1.05, 95% CI 1.02–1.09, p = 0.003), male sex, (OR 2.099, 95% CI 1.18–3.7, p = 0.012), and increased severity of illness score on admission (OR 1.044, 95% CI 1.01–1.09, p = 0.013).ConclusionDevice related pressure injuries are an all-too-common iatrogenic problem for this vulnerable patient cohort.     

Systematic review of pressure injury prevalence in Australian and New Zealand hospitals

BackgroundPressure injuries have a major impact on patients and healthcare organisations. The complications of pressure injuries increase morbidity and mortality rates and are costly to individuals and healthcare systems. The total prevalence rate of pressure injuries within acute care hospitals in Australia and New Zealand is unknown, and despite a focus on prevention, pressure injuries still occur within these hospital settings.AimTo report the prevalence of pressure injuries within acute care settings in Australian and New Zealand hospitals and to identify the stage and location of pressure injuries and analyse the methods used to conduct pressure injury point prevalence studies.MethodsA systematic review of studies published in CINAHL, MEDLINE and Cochrane databases and a two-part grey literature search, including a customised Google search and a targeted website search, was undertaken up to July 2019. The systematic review was prospectively registered with PROSPERO (CRD42018105566).FindingsThe overall prevalence of pressure injuries in acute-care hospitals in Australia and New Zealand is 12.9% (95% CI, 9.5%–16.8%) and the hospital-acquired pressure injury prevalence is 7.9% (95% CI, 5.7%–10.3%). Stage I and stage II are the most common pressure injuries. The most frequent locations for pressure injuries are the sacrum/buttock/coccyx area (41%) and the heels (31%). The reporting of details about methodology varies considerably between studies.DiscussionPressure injuries remain a significant problem within acute-care hospital settings. Total prevalence rates are decreasing over time with the numbers of stage I and II pressure injuries decreasing faster than other pressure injuries.ConclusionThe findings from this study can be used to set performance benchmarks within acute-care hospitals in Australia and New Zealand. Pressure injuries are preventable and pressure injury prevalence studies can be used to monitor the effectiveness of nursing care processes to improve patient outcomes.     

Heterogeneity hampers the identification of general pressure injury risk factors in intensive care populations: A predictive modelling analysis

ObjectiveTo determine risk factors for pressure injury in distinct intensive care subpopulations according to admission type (Medical; Surgical elective; Surgery emergency; Trauma/Burns).Methodology/designPredictive modelling using generalised linear mixed models with backward elimination on prospectively gathered data of 13 044 adult intensive care patients.Settings1110 intensive care units, 89 countries worldwide.Main outcome measuresPressure injury risk factors.ResultsA generalised linear mixed model including admission type outperformed a model without admission type (p = 0.004). Admission type Trauma/Burns was not withheld in the model and excluded from further analyses. For the other three admission types (Medical, Surgical elective, and Surgical emergency), backward elimination resulted in distinct prediction models with 23, 17, and 16 predictors, respectively, and five common predictors only. The Area Under the Receiver Operating Curve was 0.79 for Medical admissions; and 0.88 for both the Surgical elective and Surgical emergency models.ConclusionsRisk factors for pressure injury differ according to whether intensive care patients have been admitted for medical reasons, or elective or emergency surgery. Prediction models for pressure injury should target distinct subpopulations with differing pressure injury risk profiles. Type of intensive care admission is a simple and easily retrievable parameter to distinguish between such subgroups.     

Designing devices to communicate effectively with intensive care nurses to prevent pressure injuries: A qualitative study

ObjectivesThe aim of this research was to identify “what” key design elements of a device for detecting hospital acquired pressure injuries should do and “how” these elements should function. The goal of the resulting design was to prompt intensive care unit nurses to intervene appropriately to reduce the incidence/severity of pressure injuries, while minimizing workflow disruptions.MethodsA mixed method study was performed in an intensive care unit, which included shadowing, interviewing, surveying and conducting focus groups with individuals knowledgeable about pressure injuries and related patient care. This study focused on identifying and prioritizing the needs/wants of nurses regarding devices aimed at detecting hospital acquired pressure injuries. These needs were then used as the foundation for designing key elements of such a device.FindingsIntensive care nurses indicated that a device for the early detection of pressure injuries should communicate information as real-time summaries about the severity of a skin issue in an easy-to-understand manner and provide reminders for them to take action when needed without unnecessarily interrupting their workflow.ConclusionThe findings regarding nurses’ needs will be useful for the future development of technologies/devices that help reduce the incidence/severity of hospital acquired pressure injuries. In turn, nurses may be more likely to use such a device to enhance patient care.     

Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The PRESSURE study

BackgroundThe prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU).Material and methodsThis was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI.ResultsEighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6–21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6–14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU.ConclusionThis large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.     

Device-related pressure injuries in adult intensive care unit patients: An Australian and New Zealand point prevalence study

BackgroundDevice-related pressure injuries (DRPIs) are an ongoing iatrogenic problem evident in intensive care unit (ICU) settings. Critically ill patients are at high risk of developing pressure injuries caused by devices.ObjectiveThe aim of the study was to determine the prevalence of DRPI in critically ill patients in intensive care and the location, stage, and attributable device of DRPI and describe the products and processes of care used to prevent these injuries.MethodsThis was a prospective, multicentre, cross-sectional point prevalence study of patients aged more than 16 years in Australian and New Zealand ICUs. The study was part of the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program coordinated by The George Institute for Global Health.Main outcome measureIdentification of DRPI on the study day was the main outcome measure.ResultsOf the 624 patients included from 44 participating ICUs, 27 were found to have 35 identified DRPIs, giving a point prevalence DRPI rate of 4.3% (27/624). Study patients had a mean age of 59 years, and 60.3% were men. Patients with DRPI compared with patients without DRPI were significantly heavier (median: 92 kg versus 80 kg, respectively, p = 0.027), were less likely to survive the ICU (63.0% versus 85.9%, respectively, p = 0.015), had higher Acute Physiology and Chronic Health Evaluation II scores at admission to the ICU (median: 20 versus 16, respectively, p = 0.001), received mechanical ventilation more often (88.9% versus 43.5%, respectively, p < 0.001), and were more frequently diagnosed with respiratory conditions (37.0% versus 18.6%, respectively, p = 0.022). Processes of care activities were surveyed in 42 ICUs. Most DRPIs were attributed to endotracheal tubes and other respiratory devices. Forty-two ICUs reported processes of care to prevent DRPI, and just more than half of the participating sites (54.8%, 23/44) reported a dedicated ICU-based protocol for prevention of DRPI.ConclusionDRPIs pose a burden on patients in the ICU. Our study showed a DRPI prevalence comparable with other studies. Prevention strategies targeting DRPI should be included in ICU-specific pressure injury prevention guidelines or protocols.     

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials

ObjectiveThe aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings.Review method usedThis is a systematic review and meta-analysis of randomised controlled trials.Data sourcesFive databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019.Review methodsFrom an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care–specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate.ResultsOverall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I² = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I² = 0%) and heel (risk ratio = 0.31, p = 0.02; I² = 0%) prophylactic dressings for pressure injury prevention.ConclusionsOnly prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care–specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers are a potential complication for intensive care patients and their prevention is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.     

Prevalence of pressure injuries and the management of support surfaces (mattresses) in adult intensive care patients: A multicentre point prevalence study in Australia and New Zealand

BackgroundPressure injuries (PIs) are a patient safety issue that impact patient outcomes. Intensive care unit (ICU) patients are at high risk of PIs.ObjectivesTo report the prevalence and classification of documented PIs in adult ICU patients, the use of pressure injury risk assessment tools, and support surface management as a part of the prevention of PIs.MethodsThis was a prospective, single-day, multicentre, cross-sectional study of patients aged ≥ 16 years admitted to adult ICUs in Australia and New Zealand (ANZ), August 2016 as part of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) Point Prevalence Program.FindingsData were collected on 671 patients (58% male) in 47 ICUs. The mean [standard deviation] age and weight were 60.2 years [17.2 years] and 82.1 kg [29.7 kg], respectively, with a severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II) of 18.2 [8.4]. PIs were reported in 10% (70/671) of patients. Patients with a PI had a mean APACHE II score of 22.5 [standard deviation; 7.7], and 57.1% (40/70) met the criteria for sepsis on the study day. There were 107 PIs documented on the study day (N = 107) in the 70 patients with nearly half of PIs present on ICU admission (46.7%; 50/107). The sacrum was the most common location for PIs (28.9%; 31/107) and then the heels (15.9%; 17/107). All units routinely use a risk of PI assessment tool and were cared for on an active or reactive support surface. Patients with a PI were more often moved to an active support surface.ConclusionsThe prevalence rate was reported at 10% for PIs for adult intensive care patients on the study day. More than half of the patients with a PI had signs of sepsis on the study day and a higher severity of illness, and more were cared for on active support surfaces. Most PIs were located at the sacrum and then the heels. All clinical sites routinely used a PI risk assessment tool.     

Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects

OBJECTIVE: To examine age-period-duration patterns of the prevalence of pressure ulcers in community-residing people with spinal cord injury (SCI). DESIGN: Multicenter cohort study. SETTING: Nine Model Spinal Cord Injury Systems throughout the United States. PARTICIPANTS: People with SCI (N=3361) injured between 1986 and 1995 and followed up thereafter on a yearly basis through 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Physician-confirmed pressure ulcers of stage II or greater at the follow-up visits. RESULTS: The multivariable generalized estimating equations model showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993: odds ratio=1.4; 95% confidence interval, 1.2-1.6) not explained by aging, years since injury, or demographic and clinical factors. The risk of pressure ulcers appeared to be steady during the first 10 years and increased 15 years postinjury. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and other medical conditions. Injury cause and level had no significant effect. CONCLUSIONS: These results highlight the need for research into factors that contribute to the increasing pressure ulcer prevalence.     

Safety culture in two metropolitan Australian tertiary hospital intensive care units: A cross-sectional survey

BackgroundSafety culture is significant in the complex intensive care environment, where the consequences of human error can be catastrophic. Research within Australian intensive care units has been limited and little is understood about the safety culture of intensive care units in Queensland.AimThe aim was to evaluate and compare safety culture in the intensive care units of two metropolitan tertiary hospitals in Queensland.MethodA cross-sectional survey, Safety Attitudes Questionnaire, was administered to all medical, nursing and allied health professionals in the research sites (A and B) during January and February 2016. Data were collated into six safety culture domains of teamwork climate, safety climate, job satisfaction, stress recognition, working conditions and perceptions of management. Comparison was made using t-tests and between demographic groups using generalising estimating equations.ResultsIn total, 206 surveys were returned from 522 staff (39.5% response rate). The majority of respondents were nurses (80.6%). Site B scored all domains of the safety attitudes questionnaire significantly higher than Site A (p < 0.001). The scores for both site A and B were significantly higher in all domains (p < 0.001) than a previous Australian study conducted in 2013. Both sites returned low scores in the stress recognition domain. Medical staff perceived the teamwork climate as more positive than nursing staff (mean difference 16.6 [Wald χ² = 10383.8, p < 0.001]). Allied health professionals reported poorer perceptions of working conditions than medical staff (mean difference 7.8 [Wald χ² = 775.4, p < 0.001]).ConclusionDespite similar governance and external structures, differences were found in safety culture between the two research sites. This finding emphasises the importance of local, unit-level assessment of safety culture and planning of improvement strategies. This study adds to the evidence and implications for critical care clinical practice that these interventions need to be unit focused, supported by management and multidisciplinary in approach.     

Value of pressure injury assessment scales for patients in the intensive care unit: Systematic review and diagnostic test accuracy meta-analysis

ObjectivesTo review and examine the evidence of the value of pressure injury risk assessment scales in intensive care patients.Research methodologyWe searched MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, China Biomedical Literature Service System, VIP Database and CNIK from inception to February 2019. Two reviewers independently assessed articles’ eligibility and risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-II (QUADAS-2). We used a hierarchical summary receiver operating characteristics (HSROC) model to conduct the meta-analysis of diagnostic accuracy.ResultTwenty-four studies were included, involving 16 scales and 15,199 patients in intensive care settings. Results indicated that the top four risk assessment scales were the Cubbin & Jackson Index (SEN = 0.84, SPE = 0.84, AUC = 0.90), the EVRUCI scale (SEN = 0.84, SPE = 0.68, AUC = 0.82), the Braden scale (SEN = 0.78, SPE = 0.61, AUC = 0.78), the Waterlow scale (SEN = 0.63, SPE = 0.46, AUC = 0.56). The Norton scale and the other eleven scales were tested in less than two studies and need to be further researched.ConclusionThe Braden scale, most frequently used in hospitals, is not the best risk assessment tool for critically ill patients. The Cubbin & Jackson Index has good diagnostic test accuracy. However, low quality of evidence and important heterogeneity were observed.