Re: Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable.

Abstract

I read with great interest the recently published article by Pittman and colleagues examining factors associated with avoidable versus unavoidable hospital-acquired pressure injuries (HAPIs).1 I commend the authors for research on this topic, which is relevant to patients, nurses, health care administrators, quality organizations, and the Centers for Medicare and Medicaid Services.The etiology of pressure injury is multifactorial; therefore, risk detection in the critical care population is complex. Research in the past decade has demonstrated the inadequacies of using the total Braden score to assess risk of pressure injury in critical care, although scores on some Braden subscales have been found to be significant predictors.2-5 Moreover, clear definitions of both acute skin failure and unavoidable HAPI are needed to enhance our understanding of the interaction of intrinsic factors affecting oxygenation and perfusion to the skin often experienced by critically ill patients.I have several concerns and questions regarding the methods employed and the research findings. First, it is not clear how the Pressure Ulcer Prevention Inventory (PUPI) was scored. Figure 2 included 4 interventions under clinical conditions, each scored once, 6 Braden subscales with interventions scored 1 to 3 days before HAPI, a skin assessment every shift scored 1 to 3 days before HAPI, and revised interventions as appropriate scored once. This would lead to a score of 12 if counted once or an overall score of 25 for 1 to 3 days. However, in the Methods section, 13 items in the PUPI are identified. Pressure injuries were deemed unavoidable if all interventions were appropriately performed and documented with a “yes” answer to all items in the PUPI. Additionally, in the Results section, the authors described analysis of a specific number of preventive interventions. Review of the scoring method for the PUPI remained unclear to me after reading the original article as well.6 Therefore, clarification of the PUPI instrument scoring to classify a HAPI as avoidable or unavoidable would be beneficial to all readers.The findings that congestive heart failure (CHF), hypotension, and vasopressor administration were associated with avoidable HAPIs seems contradictory to 3 systematic reviews in 2017, all of which identified impaired oxygenation or perfusion (eg, CHF, hypotension, vasopressor infusion) as important HAPI risk factors.7-9 The interventions identified as preventative in Figure 3 are centered on the Braden Scale and do not encompass impaired oxygenation or perfusion. Thus, the interventions for risk factors listed in the PUPI tool are not exhaustive of all important risk factors.I was unable to determine if the PUPI tool included stratification of analysis based on HAPI site. Device site and type of devices were not described. The authors noted the limitation of PUPI use with device- related pressure injuries. No interventions to prevent device-related HAPIs were included in avoidable categorization, for example, method of device securement, prophylactic dressing under device, or rotation of device when feasible. Thus, the validity of the PUPI for categorizing device-related HAPIs is in question.Last, the comments regarding nurses’ perceptions of patients’ hemodynamic instability and inability to reposition the patient may not be discriminatory to unavoidable categorization. Because an unavoidable HAPI is also defined as a HAPI that occurs when lifesaving measures take precedence over PI prevention, it was unclear from the article how these clinical situations were addressed in terms of characterizing a HAPI as unavoidable or avoidable. Although nurses may be reluctant to mobilize patients during acute periods of perfusion or oxygenation issues, it is unclear from this study how repositioning during acute decompensation was defined or how contraindications to repositioning due to severe perfusion or oxygenation instability were considered in the research design. The period of acute decompensation, which may be 30 minutes or several hours during which the nurse and team are rescuing the patient, is likely to be when skin injury begins. In most clinical situations during which a patient is critically ill and lifesaving efforts are the priority, providing all interventions or documentation of all interventions for HAPI prevention will not be the nurse’s clinical priority. Documentation of HAPI prevention in most of these situations is done retrospectively by the nurse and appropriately not during a critical event.More research is clearly needed on HAPI risk factors to develop a scale for critical care patients. Specifically, conditions that result in impaired tissue oxygenation and perfusion are key pathophysiologic precepts that confront the majority of critically ill patients and most likely contribute to HAPIs that go beyond the prevention ability of caregivers.