Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up‐to‐date evidence‐based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.     

医疗器械相关压力性损伤预防和管理的最佳证据总结

目的探讨分析医疗器械相关压力性损伤预防及管理的证据,为临床护理人员采取针对性护理提供依据。方法采用循证方法,检索数据库及专业网站的相关文献,应用2012版临床指南研究与评价系统、2014版JBI证据预分级、证据推荐级别系统对文献进行质量评价和证据级别评定。结果最终纳入4篇指南和1篇证据总结,归纳得出22条证据,包括风险评估、医疗器械的选择和佩戴、皮肤和医疗器械的评估、预防措施4个方面。结论临床护理人员应重视医疗器械相关压力性损伤的预防及管理,根据具体临床情境、患者意愿有针对性地选择证据进行应用。     

二级医院联合社区对出院患者实施压疮延续护理的效果

目的降低出院后社区居家休养患者压疮发生率。方法组建二级医院联合社区的压疮管理网络,通过培训社区随访人员压疮相关知识,建立微信群,创立压疮管理网络工作模式,对62例二级医院出院的压疮及压疮高危患者进行管理。连续干预3个月。结果照顾者出院前、出院后1个月和3个月压疮知识、翻身操作得分比较,差异无统计学意义(均P0.05);压疮行为得分出院后显著高于出院前(均P0.01)。居家护理期间,35例压疮高危患者中发生压疮2例,发生率为5.71%;27例压疮患者,愈合15例(55.56%),好转10例(37.04%),无复发案例。结论二级医院联合社区的压疮管理网络对出院后居家休养患者实施压疮延续护理,有效改善了照顾者照顾行为,降低了压疮高危患者压疮的发生率,提高了压疮患者的治疗效果。     

Preventing pressure injuries in the emergency department: Current evidence and practice considerations

The emergency department (ED) is at the front line of hospital pressure injury (PI) prevention, yet ED clinicians must balance many competing clinical priorities in the care of seriously ill patients. This paper presents the current biomechanical and clinical evidence and management considerations to assist EDs to continue to develop and implement evidence‐based PI prevention protocols for the high‐risk emergency/trauma patient. The prevention of hospital‐acquired pressure injuries has received significant focus internationally over many years because of the additional burden that these injuries place on the patient, the additional costs and impact to the efficiency of the hospital, and the potential for litigation. The development of a PI is the result of a complex number of biomechanical, physiological, and environmental interactions. Our understanding of the interaction of these factors has improved significantly over the past 10 years. We have demonstrated that large reductions in PI incidence rates can be achieved in critical care and general hospital wards through the application of advanced evidence‐based prevention protocols and believe that further improvement can be achieved through the application of these approaches in the ED.     

The national cost of hospital‐acquired pressure injuries in the United States

Our objective was to estimate the US national cost burden of hospital‐acquired pressure injury (HAPI) using economic simulation methods. We created a Markov simulation to estimate costs for staged pressure injuries acquired during hospitalisation from the hospital perspective. The model analysed outcomes of hospitalised adults with acute illness in 1‐day cycles until all patients were terminated at the point of discharge or death. Simulations that developed a staged pressure injury after 4 days could advance from Stages 1 to 4 and accrue additional costs for Stages 3 and 4. We measured costs in 2016 US dollars representing the total cost of acute care attributable to HAPI incidence at the patient level and for the entire United States based on the previously reported epidemiology of pressure injury. US HAPI costs could exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full‐thickness wounds, which occupy clinician time and hospital resources. HAPIs remain a concern with regard to hospital quality in addition to being a major source of economic burden on the US health care system. Hospitals should invest more in quality improvement of early detection and care for pressure injury to avoid higher costs.     

2019版《压疮/压力性损伤的预防和治疗:临床实践指南》解读

从压力性损伤的定义和分类、压力性损伤的特殊人群、压力性损伤的预防、压力性损伤预防和治疗的共同措施、压力性损伤的治疗方面对2019版《压疮/压力性损伤的预防和治疗:临床实践指南》的更新进行解读,旨在让临床护理人员了解国际压力性损伤的新进展,从而提高压力性损伤预防和治疗的护理质量,减轻患者的痛苦。     

Lateral supramalleolar flap in reconstruction of pressure ulcers in patients with spinal cord injury

Pressure ulcers are a major source of morbidity in patients with spinal cord injury. Soft tissue reconstruction of pressure ulcers around the lateral malleolar region continues to be a challenge. Numerous techniques have been described in the published reports, each with their own limitations. We review our clinical experience with the lateral supramalleolar flap for reconstruction of difficult lateral malleolar pressure ulcers in patients with spinal cord injury. This study is a retrospective review of all patients who underwent this procedure between 1991 and 2005. This fasciocutaneous flap is raised on a peroneal artery perforator as its pedicle, without compromising the three vessels supplying the foot. A split-skin graft is placed on the secondary defect. The patient remains in bed for 4-6 weeks before mobilization is allowed. Eight flaps on seven patients were carried out over the study period. Patients' age ranged from 37 to 67 years (mean 56.6 years). Three patients had procedures carried out on the right and three had on the left. One patient had bilateral procedures. All flaps survived, and there were no recurrences of the pressure areas. One patient had a small area of wound breakdown at the edge of the flap, requiring debridement and split-skin graft. Another patient developed a seroma under the split-skin graft over the secondary defect, which resolved with dressings. The lateral supramalleolar flap is a simple, safe and durable flap for lateral malleolar pressure ulcer reconstruction in patients with spinal cord injury.     

Nutritional status and quality of nutrition in chronic wound patients

Malnutrition is a negative confounding factor influencing wound healing. The prevalence of malnutrition increases with age, as do chronic wounds. The aim of this prospective study was to analyse the nutritional status of patients with chronic wounds. Data collection of sociodemographic and nutritional parameters was based on an inter‐professionally developed questionnaire as well as the Mini Nutritional Assessment (MNA). A total of 90 patients with chronic wounds of different aetiologies were included. Pain and dental health were found to be significant factors: Patients with malnutrition or the risk of malnutrition had significantly lower tooth and oral health scores (rs = −0.218, P = .039), and higher pain levels at rest (rs = 0.339, P < .001), while dressing (rs = 0.268, P = .014), and upon exercising (rs = 0.303, P = .005). Our data address the impact of nutrition on chronic wounds and confirm the relationship between pain, dental health, and nutritional status. Clinicians should be aware of adequate pain management and dental health care in chronic wound patients. Further studies, particularly on characterisation of preventive and therapeutic measures in the nutrition of chronic wound patients, are of great importance.     

Associations between intracranial pressure, intraocular pressure and mean arterial pressure in patients with traumatic and non-traumatic brain injuries

Introduction

Anatomical proximity of the eye and the intracranial space is a fact but the existence of physiological and pathophysiological relationships between them is elusive. The objective of this study was to explore anatomical and pathophysiological interactions between the eye and the intracranial space and to assess clinical utility of intraocular pressure measurement in estimation of intracranial pressure in patients with brain injuries and to discover how haemodynamic instability could influence these interactions. Controversy surrounds the recent literature concerning this problem and the consensus has not been achieved.

Materials and methods

We evaluated the correlation between intracranial pressure and intraocular pressure, intracranial pressure and mean arterial pressure, intraocular pressure and mean arterial pressure in 40 patients with brain injuries initially comatose, admitted to our hospital. All patients required the intracranial pressure monitoring on clinical grounds. Simultaneous recordings of intracranial pressure, intraocular pressure and mean arterial pressure were performed.

Results

We calculated both the linear correlation coefficient and the Spearman rank-order correlation coefficient for all three relations. We found significant correlation between intraocular pressure and mean arterial pressure in 63% of the tested population. When the power of the test was increased, by considering only patients with 11 or more observations, this ratio increased to 76%. However, the correlation between intraocular pressure and intracranial pressure, as well as, between intracranial pressure and mean arterial pressure was not significant.

Conclusions

There is no anatomical and pathophysiological basis for the statement that intraocular pressure can be used as an indirect estimator of intracranial pressure.     

Risk factors and the potential of nomogram for predicting hospital‐acquired pressure injuries

This 1:5 case‐control study aimed to identify the risk factors of hospital‐acquired pressure injuries (HAPIs) and to develop a mathematical model of nomogram for the risk prediction of HAPIs. Data for 370 patients with HAPIs and 1971 patients without HAPIs were extracted from the adverse events and the electronic medical systems. They were randomly divided into two sets: training (n = 1951) and validation (n = 390). Significant risk factors were identified by univariate and multivariate analyses in the training set, followed by a nomogram constructed. Age, independent movement, sensory perception and response, moisture, perfusion, use of medical devices, compulsive position, hypoalbuminaemia, an existing pressure injury or scarring from a previous pressure injury, and surgery sufferings were considered significant risk factors and were included to construct a nomogram. In both of the training and validation sets, the areas of 0.90 under the receiver operating characteristic curves showed excellent discrimination of the nomogram; calibration plots demonstrated a good consistency between the observed probability and the nomogram's prediction; decision curve analyses exhibited preferable net benefit along with the threshold probability in the nomogram. The excellent performance of the nomogram makes it a convenient and reliable tool for the risk prediction of HAPIs.     

社区居家卧床患者压疮管理质量评价指标的构建

目的构建社区居家卧床患者压疮管理质量评价指标,以规范性评价社区居家卧床患者压疮管理质量。方法查阅国内外文献、小组讨论,形成社区压疮管理质量评价指标问卷,采用Delphi法对15名专家进行2轮咨询。结果构建的社区居家卧床患者压疮管理质量评价指标包括一级指标3项,二级指标11项,三级指标32项;专家的权威系数为0.794;2轮三级指标的协调系数分别为0.613、0.622(均P0.01)。结论社区居家卧床患者压疮管理质量评价指标及其内容可靠,经目标人群(大样本)验证后,可用于社区压疮护理质量的评价。     

Applying negative pressure therapy to deep pressure ulcers covered by soft necrotic tissue

Negative pressure therapy was applied to 39 deep pressure ulcers covered by soft necrotic tissue. All of the wounds were so deep that there were bones or ligaments just beneath the soft necrotic tissue. They had already received several types of conservative therapy including a necrotomy for periods ranging from 1 to 72 months. The wounds were minimally debrided and put in an adequately wet environment with negative pressure. This environment was established by the application of a suction‐dressing. All of these wounds showed clear wound beds within only 1 month. All of the wounds were successfully cured, either with or without a musculocutaneous flap. Negative pressure wound therapy is thus considered to be one of the choices for the management of non healing deep pressure ulcers covered by soft necrotic tissue.     

Characteristics of hospitalised US veterans with nosocomial pressure ulcers

The objective of this study was to describe demographic and clinical characteristics of hospitalised US veterans with nosocomial pressure ulcer (NPU) referred to a certified Wound, Ostomy & Continence Nurse (WOCN). We conducted a retrospective review of electronic records at a Veterans Affairs Medical Center in the northwestern USA. Records of veterans with NPU referred to a WOCN (n = 29) from May 2005 to June 2006 were reviewed. Location and stage of pressure ulcer(s), Braden score on admission and when the ulcer was first noted, day of hospital stay when the ulcer was first noted, medical diagnoses and clinical conditions and events such as surgery, hypoxemia, hypoalbuminemia and hypotension were recorded. Mean age of the patients was 69·8. The most common location was the sacrum/coccyx. Most ulcers were stage 1 when identified. Braden score during admission classified half of the sample at risk, but 81% of Braden scores at ulcer occurrence were <18. Ninety percent of the sample had three or more comorbidities. Over half had died in the 1–14 months after the reviewed hospitalisation. Hospitalised veterans referred for WOCN consultation had multiple risk factors and comorbid conditions, including hypoxemia, serum albumin depletion, anaemia and hypotension. Veterans cared for in Veterans Affairs Medical Centers are known to have multiple health problems, and those in this sample not only had nosocomial pressure ulcer, but also other physiological derangements that may shorten survival.     

Risk for undernutrition and development of pressure injury in hospitalised patients in Brazil: Multicentre prospective cohort study

Although pressure injury (PI) is preventable, the number of patients developing this type of injury is still high. In this prospective cohort study, we aimed to assess whether high risk for undernutrition was a risk factor for PI in 1937 patients aged ≥18 at six hospitals in Sao Paulo, Brazil. Patients'' risk for undernutrition was assessed using three unique screening tools. Risk for PI was assessed using the Braden Scale. Data were analysed using Poisson regression with robust variance (95% CI, P ≤ .05). While 57.1% of patients were at risk for undernutrition in the Nutritional Risk Screening (NRS 2002), only 36.8% and 2.6% were at risk in the Braden Scale Nutrition Subscale (BSNS) and Subjective Global Assessment of Nutritional Status (SGANS), respectively. The cumulative incidence rate was 5.9%. Of those who developed PI, 91.2%, 56.2%, and 18.4% were at risk for undernutrition in the NRS 2002, BSNS, and SGANS scales, respectively. We found a significantly higher risk for PI in patients who were at risk for undernutrition compared with those who were not at risk, supporting previous evidence about the role of undernutrition as a key risk factor for PI in hospitalised patients.     

Evidence‐based review of the effects of nutritional supplementation for pressure ulcer prevention

The objective of this evidence‐based review was to explore whether the evidence supports the use of nutritional supplements in pressure ulcer (PU) prevention strategies. Several electronic databases, including Ovid MEDLINE (1946 to May week 32 019), Ovid EMBASE (1947 to May 28, 2019), EBSCO CINAHL (until June 13, 2019), Scopus (until July 9, 2019), and the Web of Science (until June 13, 2019) were searched. No limitation was placed on the year of publication. Studies considered for inclusion were those with adult populations, and only English language texts with available full text were reviewed. AMSTAR (a measurement tool to assess systematic reviews) was used to evaluate the quality of the studies included in the systematic review. The Oxford Centre for Evidence‐Based Medicine (OCEBM) 2011 Levels of Evidence was used to assess the level of evidence. Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) was used to assess guideline article, and Appraisal tool for Cross‐Sectional Studies (AXIS) was also used for cross‐sectional studies. The search identified 1761 studies. After the application of inclusion and exclusion criteria, 24 studies were retained of various designs, including 10 systematic reviews, five clinical reviews, three randomised controlled trials, two observational studies, one quasi‐experimental study, one cross‐sectional study, one cohort study, and one Clinical Guideline. Two were rated as high‐quality reviews, 14 were rated as moderate‐quality reviews, five were rated as low‐quality reviews, and three were rated as critically low‐quality reviews. The majority of the reviewed studies were of low‐to‐moderate quality because of biases in the study design and incomplete data reporting, which did not fulfil the reporting criteria of the appraisal tools. However, the majority of the studies showed a reduction in PU incidence after nutritional supplement though not significant. Whether the use of pharmacological appraisal tools to assess non‐pharmacological studies is appropriate is unclear. Regardless of the low‐to‐moderate quality of the studies in this review, nutritional supplements appear to play a role in PU prevention.     

基于闭环管理的压疮系统构建

目的优化压疮管理流程,做到环节管理及质量持续改进。方法在医院信息系统(HIS)建立压疮管理模块,与6级电子病历有效结合,通过压疮监控模块筛查高危患者并进行预警提示,对不同来源压疮数据信息上报,并记录治疗护理措施、压疮愈合等情况。结果实施压疮闭环管理后,2013~2015年压疮发生率分别为0.06%、0.06%、0.08%,低于国内12所医院的调研结果。结论压疮闭环管理体系的构建能够科学分析压疮发生现状,对治疗护理过程中存在的问题进行整改,进而提高压疮护理和管理质量。     

Functional splinting of upper limb injuries with gauze-based topical negative pressure wound therapy

Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negative-pressure dressing system.     

Turning frequency in adult bedridden patients to prevent hospital‐acquired pressure ulcer: A scoping review

The aim of this study was to identify current research on turning frequencies of adult bed‐bound patients and inform future turning practices for hospitals based on evidence‐based practice. We undertook a scoping review framework that provided a transparent and systematic methodology using 8 electronic databases (CINAHL, PubMed, Cochrane Library, ScienceDirect, PsycINFO, Scopus, ProQuest, and Web of Science) to identify articles published from 2000 to 2016. Articles were included if they focused on the prevention of hospital‐acquired pressure ulcers related to the frequency of turning or repositioning of bed‐bound patients. Literature search and data extraction were performed independently by 3 authors. The study followed the PRISMA guidelines. In total, 911 articles were identified, of which 10 were eligible. Of the eligible articles, 8 studies could not reach a conclusion on the effective frequency of turning and duration for repositioning patients to prevent the development of pressure ulcers. Only 2 studies found significant differences among the intervention and control groups. Results regarding turning and repositioning schedules are inconclusive; however, the topic needs further exploration to improve the outdated guidelines surrounding pressure ulcer prevention. This may, in turn, make the work of nurses more efficient and make treatment cost‐effective for both the patients and the hospitals.     

Clinical and cost effectiveness of a system for turning and positioning intensive care unit patients,when compared to usual care turning and positioning devices,for the prevention of hospital-acquired pressure injuries. A randomised controlled trial

Pressure injuries affect 13.1% to 45.5% of patients in the intensive care unit and lead to pain and discomfort for patients, burden on healthcare providers, and unnecessary cost to the health system. Turning and positioning systems offer improvements on usual care devices, however the evidence of the effectiveness of such systems is still emerging. We conducted an investigator initiated, prospective, single centre, two group, non-blinded, randomised controlled trial to determine the effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for preventing PIs. The trial was prematurely discontinued after enrolment of 78 participants due to COVID-19 pandemic related challenges and lower than expected enrolment rate. The study groups were comparable on baseline characteristics and adherence to the interventions was high. Four participants developed a PI (in the sacral, ischial tuberosity or buttock region), n = 2 each in the intervention and control group. Each participant developed one PI. As the trial is underpowered, these findings do not provide an indication of the clinical effectiveness of the interventions. There was no participant drop-out or withdrawal and there were no adverse events, device deficiencies, or adverse device effects identified or reported. The results of our study (in particular those pertaining to enrolment, intervention adherence and safety) provide considerations for future trials that seek to investigate how to prevent PIs among ICU patients.     

老年肠内营养患者项目管理法的护理实践

目的探讨项目管理法在老年患者肠内营养护理中的应用效果。方法将有营养不良风险或营养不良的老年患者216例按住院时间分为两组,观察组(108例)采用项目管理法进行营养护理,对照组(108例)采用常规方法进行营养护理。比较干预3个月后两组患者肠内营养并发症的发生情况,老年简易营养评估量表得分、血红蛋白、血清白蛋白。结果两组肠内营养并发症发生率比较,差异无统计学意义(均P 0. 05),观察组老年简易营养评估量表得分、血红蛋白、血清白蛋白显著优于对照组(P 0. 05,P 0. 01)。结论项目管理利于营养护理过程实施监测和管控,保证项目的顺利开展,提高老年患者的营养指标。