Evidence-Based Review and Discussion Points

Abstract

Hospital-acquired pressure injuries (HAPIs) are presumed to be preventable injuries that can have a substantial impact on the outcomes of acutely and critically ill patients. To minimize additional harm from HAPIs, most health care organizations have implemented evidence-based strategies to reduce the occurrence of HAPIs. Yet national organizations, such as the Center for Medicaid and Medicare Services, the National Pressure Ulcer Advisory Panel, and the Wound, Ostomy, and Continence Nurses Society, recognize that some HAPIs are unavoidable even if the patients are exposed to evidence-based prevention strategies. Predicting which patients will have HAPIs develop is a recognized research priority. Patients in whom unavoidable HAPIs develop are typically at higher risk for HAPIs, and preventative strategies are likely to be contraindicated or ineffective.Determination of which patients are at risk for an unavoidable HAPI is limited by a lack of reliable and valid measures. To address this gap in evidence and identify at-risk patients in critical care or progressive care units, the authors of this EBR article conducted a retrospective, descriptive comparative study to determine the proportion of HAPIs that met the classification as unavoidable and to explore which patient characteristics were associated with an avoidable or unavoidable HAPI. Guided by a conceptual framework for differentiating unavoidable from avoidable pressure ulcers, the authors examined data from 165 acutely and critically ill adults who had a HAPI develop while convalescing in a critical care or progressive care unit. The authors used the methods from the National Database Nursing of Quality Indicators to identify patients with a HAPI, and an investigator-developed tool (the Pressure Ulcer Prevention Inventory) was used to classify the HAPI as avoidable versus unavoidable using abstracted data from the electronic medical records of the patients who met the inclusion criteria.The authors found that nearly half (41%) of their sample of acutely and critically ill patients had an unavoidable HAPI develop. Several patient characteristics were associated with the risk of an unavoidable HAPI. Patients who had a diagnosis of congestive heart failure, longer stays before the HAPI was identified, and a history of a prior pressure injury were more likely to have an unavoidable HAPI; these results were found when the following factors were controlled for: comorbidity; daily Braden scale scores; history of smoking; the need for chemical sedation, a bowel management system, or vasopressors; as well as hypotension (systolic blood pressure < 90 mm Hg). Additionally, the authors established that patients who had an avoidable HAPI develop had fewer prevention strategies implemented compared with patients classified by using the Pressure Ulcer Prevention Inventory as having an unavoidable HAPI develop. The authors conclude that the risk factors that differentiate patients with avoidable and unavoidable HAPIs are primarily related to their exposure to HAPI prevention strategies.Joyce Pittman, phd, rn, anp-bc, fnp-bc, cwocn, faan, lead author of this EBR article, provides additional information about the study. She says that her interest in the prevention of HAPIs began while working as a critical care nurse. “I never realized the magnitude of the prevalence of pressure injuries until [I was] leading prevalence surveys within the hospital setting,” shares Dr Pittman.As a critical care nurse, Dr Pittman recognized that the focus of critical care services is often on lifesaving therapies and that pressure injury prevention was not consistently a high priority in this clinical context. She explains that critical care patients have multiple risk factors for pressure injuries plus states of inadequate tissue perfusion that can lead to failure of skin integrity. “Yet, when those patients exhibit signs and symptoms of poor skin perfusion, and nurses provide pressure injury prevention care, we do not differentiate these pressure injuries from those in which patients were not exposed to the best care practices,” she adds.According to Dr Pittman, the findings of her study have significant relevance to nurses practicing in a critical care or progressive care unit. Specifically, she comments that the study findings establish that not all pressure injuries are avoidable and that sometimes, even when nurses do everything right, pressures injuries still occur. “On the other hand, we found that 60% of the time, we [nurses] missed something and a pressure injury resulted, and pressure injury prevention care must be done consistently,” she remarks.Dr Pittman encourages readers of the American Journal of Critical Care to consistently implement pressure injury prevention strategies when providing nursing care to acutely or critically ill patients. Pittman and her coauthors point out that the findings of their study underscore the importance of pressure injury documentation and implementation of pressure injury prevention care. Continued research is needed to examine unavoidable HAPIs in critically ill patients. Use of a more rigorous design (eg, control group) is one direction for future research, and elucidating factors that lead to acute skin failure is another direction, one that Pittman and her team have already begun to examine.This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Joyce Pittman, phd, rn, anp-bc, fnp-bc, cwocn, faan, is an associate professor at the University of South Alabama, College of Nursing. She is a nurse scientist and an advanced practice nurse with more than 3 decades of experience in clinical practice. Dr Pittman’s practice and research are focused on improving the quality of life of patients with wound, ostomy, and continence issues.Leading this study was a stepping stone for Dr Pittman that allowed her to advance her professional involvement in pressure injury prevention. “I am on the National Pressure Ulcer Advisory Panel and am involved in the committee for the 2019 International Pressure Ulcer/Injury Prevention and Treatment Guidelines,” she notes.Dr Pittman hopes that her work with these national and international organizations, as well as the results of this study, will garner the attention of the Centers for Medicare and Medicaid Services to consider the presence of unavoidable pressure injuries in acute care settings.