Response.

Abstract

We want to express our gratitude to Dr Schallom for her thoughtful comments and interest in our work related to avoidable versus unavoidable hospital-acquired pressure injuries (HAPI). We agree the etiology of pressure injuries is multifactorial and risk prediction is complex. Critically ill patients often have additional risk factors that are not well addressed in the Braden Scale. As shown in the conceptual framework in the article,1 tissue perfusion is a risk factor affecting tissue tolerance of the patient and should be considered.We included the Pressure Ulcer/Injury Prevention Inventory (PUPI) instrument and other data collection forms in the article for the convenience of the readers; however, because of word limitations and conciseness, not all instructions for its use were provided in the AJCC article. Detailed instructions accompany the PUPI and other data collection forms used in our study. We provided extensive and ongoing training for the team that collected the data. The PUPI has 4 main domains (1, clinical condition evaluation; 2, defined and implemented interventions consistent with patient’s needs; 3, monitored/evaluated impact of interventions; and 4, revised interventions as appropriate) and 1 final determination (pressure ulcer avoidable, yes/no). The 13 specific items include the 4 items under (1) clinical condition; 6 items under (2) defined and implemented interventions consistent with patient’s needs; 1 item under (3) monitored/evaluated impact of interventions; 1 item for (4) revised interventions as appropriate; and 1 item for pressure ulcer avoidable.Your comments regarding congestive heart failure, hypotension, and vasopressor administration are pertinent and we agree are difficult to explain. However, the systematic reviews you cite report risk factors for all HAPI. In our study, we tried to differentiate risk factors between those HAPI that were avoidable or unavoidable and were unable to do so. We are currently completing a study where we are analyzing a case-matched group (HAPI and non-HAPI) that will provide interesting information related to this issue.We did not stratify our analysis of the PUPI tool according to HAPI site. Medical device–related pressure injuries were included in our data, but we did not report the location or device in the article. We identified a limitation of the PUPI related to medical device– related pressure injuries for 2 reasons. First, the PUPI is based on the Braden subscales, which do not address medical device–related pressure injuries well. The second reason was that documentation of appropriate interventions related to prevention of medical device– related pressure injuries was limited in our electronic health record (EHR). Our research identified this lack of documentation, which led to improvement efforts being implemented into the EHR.Finally, your comment related to decompensation and inability to reposition the critically ill patient is duly noted. These are often key risk factors that lead to pressure injury development. Multiple organizations have recognized that some pressure injuries may be unavoidable.2-4 In our study, we addressed this issue by including an exception item in our data collection form. For example, if repositioning was not performed but an exception was noted (decompensation, support surface that did not allow repositioning, etc), this was taken into account when completing the PUPI.We hope our explanation and clarification have helped to address and answer your concerns. Again, we appreciate your interest and attention to detail, which is so important when appraising the available evidence.