Hospital-acquired Pressure Injuries Research Articles

Effect of a Hospital-Acquired Pressure Injury (HAPI) Risk Score on HAPI Rates in Patients With Vascular Diseases.

The purpose of this study was to assess whether a validated hospital-acquired pressure injury (HAPI) risk scale and best practice interventions were associated with lower HAPI rates compared with previous care. We also sought to identify a cut score of HAPI risk when using the instrument. Nonequivalent 2-group pre- and postintervention comparative study. The sample comprised 2871 patients treated for vascular diseases; data were collected on 2674 patients before the intervention and 197 patients postintervention. Their mean (SD) age was 69.3 (12.4) years; 29.3% (n = 842) had a history of diabetes mellitus. Based on discharge status, more patients received home health care after discharge in the postintervention group, 34% (n = 67/197) versus 16.2% (n = 430/2662), P = .001. The study setting was a quaternary care hospital in the Midwestern United States. Patients who were at high risk for HAPI, based on a nomogram score, received a mobility and ambulation program intervention. Pre- and postintervention cohorts were compared using analysis of variance, χ 2 test, and Fisher exact test. A receiver operating characteristic curve plot was generated to determine the ability of the risk score tool to identify HAPI risk at all possible cut points. Despite differences in patient characteristics, primary medical diagnosis, and postdischarge health care needs, the HAPI rate decreased postintervention from 13.8% (n = 370/2674) to 1.5% (n = 3/197), P = .001. A HAPI risk-predicted value cut score of 18 had strong sensitivity (0.81) and specificity (0.81), and positive and negative predictive values of 0.42 and 0.96, respectively. Despite higher patient acuity during the intervention period, HAPI rate decreased after HAPI nomogram and nurse-led mobility intervention implementation.

An Integrated System of Multifaceted Machine Learning Models to Predict If and When Hospital-Acquired Pressure Injuries (Bedsores) Occur

Hospital-Acquired Pressure Injury (HAPI), known as bedsore or decubitus ulcer, is one of the most common health conditions in the United States. Machine learning has been used to predict HAPI. This is insufficient information for the clinical team because knowing who would develop HAPI in the future does not help differentiate the severity of those predicted cases. This research develops an integrated system of multifaceted machine learning models to predict if and when HAPI occurs. Phase 1 integrates Genetic Algorithm with Cost-Sensitive Support Vector Machine (GA-CS-SVM) to handle the high imbalance HAPI dataset to predict if patients will develop HAPI. Phase 2 adopts Grid Search with SVM (GS-SVM) to predict when HAPI will occur for at-risk patients. This helps to prioritize who is at the highest risk and when that risk will be highest. The performance of the developed models is compared with state-of-the-art models in the literature. GA-CS-SVM achieved the best Area Under the Curve (AUC) (75.79 ± 0.58) and G-mean (75.73 ± 0.59), while GS-SVM achieved the best AUC (75.06) and G-mean (75.06). The research outcomes will help prioritize at-risk patients, allocate targeted resources and aid with better medical staff planning to provide intervention to those patients.

Implementing a Two-RN Skin Assessment to Reduce Hospital-Acquired Pressure Injuries

Implementing a Two-RN Skin Assessment to Reduce Hospital-Acquired Pressure Injuries

Reducing Hospital-Acquired Pressure Injuries Through Use of a Skin Bundle

Reducing Hospital-Acquired Pressure Injuries Through Use of a Skin Bundle

A Hybrid System of Braden Scale and Machine Learning to Predict Hospital-Acquired Pressure Injuries (Bedsores): A Retrospective Observational Cohort Study

Background: The Braden Scale is commonly used to determine Hospital-Acquired Pressure Injuries (HAPI). However, the volume of patients who are identified as being at risk stretches already limited resources, and caregivers are limited by the number of factors that can reasonably assess during patient care. In the last decade, machine learning techniques have been used to predict HAPI by utilizing related risk factors. Nevertheless, none of these studies consider the change in patient status from admission until discharge. Objectives: To develop an integrated system of Braden and machine learning to predict HAPI and assist with resource allocation for early interventions. The proposed approach captures the change in patients' risk by assessing factors three times across hospitalization. Design: Retrospective observational cohort study. Setting(s): This research was conducted at ChristianaCare hospital in Delaware, United States. Participants: Patients discharged between May 2020 and February 2022. Patients with HAPI were identified from Nursing documents (N = 15,889). Methods: Support Vector Machine (SVM) was adopted to predict patients' risk for developing HAPI using multiple risk factors in addition to Braden. Multiple performance metrics were used to compare the results of the integrated system versus Braden alone. Results: The HAPI rate is 3%. The integrated system achieved better sensitivity (74.29 ± 1.23) and detection prevalence (24.27 ± 0.16) than the Braden scale alone (sensitivity (66.90 ± 4.66) and detection prevalence (41.96 ± 1.35)). The most important risk factors to predict HAPI were Braden sub-factors, overall Braden, visiting ICU during hospitalization, and Glasgow coma score. Conclusions: The integrated system which combines SVM with Braden offers better performance than Braden and reduces the number of patients identified as at-risk. Furthermore, it allows for better allocation of resources to high-risk patients. It will result in cost savings and better utilization of resources. Relevance to clinical practice: The developed model provides an automated system to predict HAPI patients in real time and allows for ongoing intervention for patients identified as at-risk. Moreover, the integrated system is used to determine the number of nurses needed for early interventions. Reporting Method: EQUATOR guidelines (TRIPOD) were adopted in this research to develop the prediction model. Patient or Public Contribution: This research was based on a secondary analysis of patients' Electronic Health Records. The dataset was de-identified and patient identifiers were removed before processing and modeling.

Reducing hospital acquired pressure injury in a learning health center: Making the case for quality.

The purpose of this descriptive study is to examine a learning health system (LHS) continuous improvement and learning approach as a case for increased quality, standardized processes, redesigned workflows, and better resource utilization. Hospital acquired pressure injuries (HAPI) commonly occur in the hospitalized patient and are costly and preventable. This study examines the effect of a LHS approach to reducing HAPI within a large academic medical center. Our learning health center implemented a 6-year series of iterative improvements that included both process and technology changes, with robust data and analytical reforms. In this descriptive, observational study, we retrospectively examined longitudinal data from April 1, 2018 to March 31, 2022, examining the variables of total number of all-stage HAPI counts and average length of stay (ALOS). We also analyzed patient characteristics observed/expected mortality ratios, as well as total patient days, and the case-mix index to determine whether these factors varied over the study period. We used the Agency for Healthcare Research and Quality cost estimates to identify the estimated financial benefit of HAPI reductions on an annualized basis. HAPI per 1000 patient days for FY 20 (October 1-September 30) and FY 21, decreased from 2.30 to 1.30 and annualized event AHRQ cost estimates for HAPI decreased by $4 786 980 from FY 20 to FY 21. A strong, statistically significant, negative and seemingly counterintuitive correlation was found (r=-.524, P=.003) between HAPI and ALOS. The LHS efforts directed toward HAPI reduction led to sustained improvements during the study period. These results demonstrate the benefits of a holistic approach to quality improvement offered by the LHS model. The LHS model goes beyond a problem-based approach to process improvement. Rather than targeting a specific problem to solve, the LHS system creates structures that yield process improvement benefits over a continued time period.

The Creation of a Critical Care Admission Pressure Injury Prevention Cart to Reduce Hospital-Acquired Pressure Injuries

The goal of this process improvement initiative is to reduce hospital-acquired pressure injuries related to Covid-19 with Critical Care patients. Critically ill and ventilated patients require prone position therapy and prolonged ventilator times place the patient at risk for hospital acquired conditions and pressure injuries. The Critical Care team created a Critical Care Admission Pressure Injury Prevention Cart that contains preventative dressings for all pressure areas at risk. The Critical Care Admission Pressure Injury Prevention Cart has significantly reduced the pressure injury rate. With the emergence of the pandemic and additional surges, pressure injuries continued to be on the rise due to prone position therapy. The Critical Care team worked with the system and developed prone position protocols, which included preventative dressings for all areas at risk. Prior to the implementation of the admission cart, Critical Care ended fiscal year 2022, quarter one, with fifty-three hospital acquired pressure injuries. Last December and early January 2022 there was another surge of Covid-19. The Critical Care team implemented the admission cart in January 2022. From January 2022 through September 2022, there has been an 98% reduction. The cart has been successful for Critical Care, and Baptist Hospital implemented the cart in all high acuity areas. This cart was a multidisciplinary practice, which consists of nursing, the wound and skin team, respiratory care, and leadership working together towards the goal of patient safety and pressure injury prevention.

Pressure Injury Risk Assessment and Associations in an Adult Inpatient Rehabilitation Sample- Retrospective Cohort Study

<h3>Research Objectives</h3> To identify risk factors for the development of Hospital Acquired Pressure Injury (HAPI) over 6 months in an Inpatient Rehabilitation Facility (IRF) using the Braden Scale for Pressure Injury Prevention (Braden) and other variables. <h3>Design</h3> Observational Retrospective Cohort Study. <h3>Setting</h3> 262 bed free-standing IRF at an urban academic medical center. <h3>Participants</h3> Adults 18 years and older admitted to IRF from July through December 2020 were included. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Logistic regression is used to assess HAPI occurrence during episode of care, against possible predictors including the Braden total score, Braden subscales, demographics, lab albumen, pain, diagnosis-related impairment group, external medical/orthopedic devices, expression of ideas/wants and understanding of verbal content. <h3>Results</h3> Of 1342 unique patients with 1494 episode of care, 54 (3.6%) HAPI events occurred. Before adjustment, Braden total score of 15 (14.69, SD 1.92) and below was associated with increased HAPI occurrence (p< 0.001). Univariate analyses identified the following significant risk factors for HAPI: age, impairment group, gastrointestinal tube, urinary catheter, expression of ideas/wants and understanding of verbal content. After adjusting for these variables, each one-point increase was associated with a 23% reduced odds of HAPI occurrence (95% CI, 0.65-0.90; p< 0.001). Three variables were still strongly associated with increased HAPI occurrence: Braden subscale "Friction/Shear" (OR 0.47; 95%CI, 0.27-0.81; p< 0.007), presence of a gastrointestinal tube (OR 2.51 higher odds; 95%CI, 1.03-5.66; p< 0.001), and rarely/never expresses ideas/wants (OR 9.16 higher odds; 95%CI, 0.94-70.05; p< 0.04) compared to no difficulty. Impairment group modified the effects: People with Spinal Cord Injury (SCI) had a greater odds of HAPI occurrence compared to those with Brain (OR 0.28; 95% CI, 0.11-0.66; p< 0.001) and Medically Complex (OR 0.31; 95% CI, 0.15-0.63; p< 0.001) impairments. <h3>Conclusions</h3> This study builds on prior SCI-related Braden research by including all patients admitted to IRF. Clinicians should consider adult IRF patients at risk for HAPI with Braden total scores of 15 and below, worse problems of "Friction/Shear", presence of a gastrointestinal tube, and patient's inability to express ideas/wants. <h3>Author(s) Disclosures</h3> N/A.

Improving Hospital-Acquired Pressure Injury Outcomes by Overcoming Barriers to Implementing Patient Positioning Devices.

Improving Hospital-Acquired Pressure Injury Outcomes by Overcoming Barriers to Implementing Patient Positioning Devices.

MSR17 Modernizing Pressure Injury Risk Assessment in the ICU in the COVID Era: Ensemble Super-Learning and Explainable AI

Hospital-acquired pressure injuries (HAPrI) are areas of injury to the skin and/or underlying tissues. Risk stratification is essential for guiding prevention in the ICU, but current risk assessment tools require labor-intensive input. This motivates a tactical, parsimonious, and automatic risk profiling algorithm, that can be based on readily available clinical measures (e.g., COVID status, race, Medicare/Medicaid status). Additionally, International Pressure Injury Prevention guidelines call for the development of machine learning-based risk assessment algorithms that are clinician-interpretable and context-informed.

Incidence of Hospital-Acquired Pressure Injury among Adult Inpatients at Kakamega County General Hospital, Kenya

A hospital-acquired pressure injury is a largely preventable adverse health event, which has remained high volume and high cost globally hence a significant concern in healthcare. This study used a prospective cohort model between April and July 2021 to determine the incidence of these injuries among adults at the Kakamega County General Hospital in Kenya, thus informing the need for scaled-up intervention strategies to eliminate these preventable harms on patients receiving care in line with international patients’ safety goal. Eighty participants above 18 years of age, systematically drawn from the male and female medical, surgical, and orthopaedic hospitalisation units, were followed up through their hospital stay for the development of pressure injury. Sociodemographic characteristics, units of hospitalisation, diagnosis and clinical variables were studied and outcomes were recorded, coded, and analysed on the statistical package for social sciences version 26. This study found an overall incidence rate of 15%, with men at 17.5% against women at 12.5%. The most affected site was the sacrum region accounting for 35.7% of all cases, with a mean day of occurrence at 5.58 days post-hospitalisation. This high incidence signifies pressure injury as a threat to healthcare quality, equity, and cost in Kakamega and Kenya. The Ministry of Heath should therefore adopt, customise, and implement the international guidelines on pressure injury to curb this menace. A multidisciplinary approach should be used, prioritising patients at increased risk and providing suitable prevention and treatment from the earliest opportunity

A Comparison of Two Multi-Layer Sacral Foam Dressings for the Prevention of Hospital-Acquired Pressure Injuries.

Hospital-acquired pressure injuries (HAPIs) represent a significant detriment to patient health by increasing mortality risk, negatively impacting quality of life, and increasing risk of complications such as infection. Prophylactic use of sacral foam dressings is known to decrease the occurrence of HAPIs in various patient populations. This retrospective study compared the effect of two multi-layer sacral foam dressings on HAPI incidence in patients admitted to a short-term, acute care hospital during the years 2015 (dressing one: Mepilex® Border Protect sacral dressing [Mölnlycke Healthcare AB, Göteborg, Sweden]) and 2017 (dressing two: Optifoam® Gentle LQ silicone faced foam < border sacral dressing [Medline Industries, LP, Northfield, Illinois]). Patient medical charts were examined for full sample (n=297) and subsample (n=284) analysis, respectively. The HAPI incidence for dressing two was found to be significantly less than dressing one (full sample: 5.12% compared to 10.79% [p=0.0001], and subsample: 4.07% compared to 9.31% [p=0.0001]). The incidence rate ratio (IRR) for dressing two was 0.39 for the full sample and 0.35 for the subsample, indicating that compared to dressing one, the HAPI count was approximately 40% lower for dressing two for the full sample and approximately 35% lower for dressing two for the subsample. These results demonstrate that dressing two performed better than dressing one in HAPI prevention. The results of this study may inform clinicians in their choice of prophylactic dressings.

A systematic review of predictive models for hospital-acquired pressure injury using machine learning.

To summarize the use of machine learning (ML) for hospital-acquired pressure injury (HAPI) prediction and to systematically assess the performance and construction process of ML models to provide references for establishing high-quality ML predictive models. As an adverse event, HAPI seriously affects patient prognosis and quality of life, and causes unnecessary medical investment. At present, the performance of various scales used to predict HAPIs is still unsatisfactory. As a new statistical tool, ML has been applied to predict HAPIs. However, its performance has varied in different studies; moreover, some deficiencies in the model construction process were observed in each study. Systematic review. Relevant articles published between 2010-2021 were identified in the PubMed, Web of Science, Scopus, Embase and CINHAL databases. Study selection was performed in accordance with the preferred reporting items for systematic reviews and meta-analysis guidelines. The quality of the included articles was assessed using the prediction model risk of bias assessment tool. Twenty-three studies out of 1793 articles were considered in this systematic review. The sample size of each study ranged from 149-75353; the prevalence of pressure injuries ranged from 0.5%-49.8%. ML showed good performance for HAPI prediction. However, some deficiencies were observed in terms of data management, data pre-processing and model validation. ML, as a powerful decision-making assistance tool, is helpful for the prediction of HAPIs. However, existing studies have been insufficient in terms of data management, data pre-processing and model validation. Future studies should address these issues to establish ML models for HAPI prediction that can be widely used in clinical practice. This review highlights that ML is helpful in predicting HAPI; however, in the process of data management, data pre-processing and model validation, some deficiencies still need to be addressed. The ultimate goal of integrating ML into HAPI prediction is to develop a practical clinical decision-making tool. A complete and rigorous model construction process should be followed in future studies to develop high-quality ML models that can be applied in clinical practice.

The clinical effectiveness of an integrated multidisciplinary evidence-based program to prevent intraoperative pressure injuries in high-risk children undergoing long-duration surgical procedures: A quality improvement study.

The prevention of hospital-acquired pressure injuries (HAPIs) in children undergoing long-duration surgical procedures is of critical importance due to the potential for catastrophic sequelae of these generally preventable injuries for the child and their family. Long-duration surgical procedures in children have the potential to result in high rates of HAPI due to physiological factors and the difficulty or impossibility of repositioning these patients intraoperatively. We developed and implemented a multi-modal, multi-disciplinary translational HAPI prevention quality improvement program at a large European Paediatric University Teaching Hospital. The intervention comprised the establishment of wound prevention teams, modified HAPI risk assessment tools, specific education, and the use of prophylactic dressings and fluidized positioners during long-duration surgical procedures. As part of the evaluation of the effectiveness of the program in reducing intraoperative HAPI, we conducted a prospective cohort study of 200 children undergoing long-duration surgical procedures and compared their outcomes with a matched historical cohort of 200 children who had undergone similar surgery the previous year. The findings demonstrated a reduction in HAPI in the intervention cohort of 80% (p < 0.01) compared to the comparator group when controlling for age, pathology, comorbidity, and surgical duration. We believe that the findings demonstrate that it is possible to significantly decrease HAPI incidence in these highly vulnerable children by using an evidence-based, multi-modal, multidisciplinary HAPI prevention strategy.

Pressure injury screening in the emergency department: A concept analysis.

This concept analysis analyzes pressure injury screening in the emergency department setting using Walker and Avant's approach. Pressure injury treatment cost in the United States totals over 11 billion dollars annually. Although a pressure injury could develop in the few hours a patient is in the emergency department, there is little guidance on how an emergency department should screen, prevent, and treat patients. Five sources resulted from database searches of CINAHL full-text, Health Business FullTEXT, and MEDLINE with Full Text. Key search terms used to narrow the search consist of the following terminology: "pressure injury" OR "pressure ulcer" AND "screening" AND "risk factors" AND "emergency room" OR "emergency department. Walker and Avant's method of concept analysis was used to clarify the concept of pressure injury screening in the emergency department. The concept analysis identified two attributes of pressure injury screening in the emergency department: patient length of stay and the cost of pressure injury treatment. Antecedents identified are patient risk factors: age, mobility status, sensory perception, comorbidities, and pre-existing pressure injuries. Positive consequences identified are increased patient comfort, increased staff satisfaction, decreased hospital-acquired pressure injuries, and increased adherence to established treatment protocols. This concept analysis may help to guide evidence-based practice for pressure injury screening in the emergency setting. Perhaps screening in the emergency department, if adopted globally, is the missing element needed to finally see a reduction in pressure injury rates.

Absence of oral nutritional support in low food intake inpatients is associated with an increased risk of hospital-acquired pressure injury.

Hospital-acquired pressure injury (HAPI) incidence is a common burden in hospitals. Decreased food intake leading to malnutrition compromises body tissues involved in pressure injury occurrence. However, most tools for predicting pressure injuries do not include daily food intake monitoring nor consider further nutritional interventions. This study aimed to investigate clinical practices for food intake monitoring and its association with predicting HAPI risk, together with Norton Scale use, and whether the initiation or absence of oral nutritional supplements (ONS), separately from other nutritional interventions, was associated with HAPI incidence in low food intake inpatients, who consumed less than 50% of requirements. This observational cohort study covered a one-year period (08/2018-07/2019). Demographic and clinical data were extracted from computerized files of patients hospitalized ≥7 days, aged ≥60 years, and who ate orally. Patients receiving enteral or parenteral nutrition were excluded. Differences were studied between groups without and with HAPI grade ≥2. Subgroups divided by Norton Scale and intake, Norton Scale and albumin levels, food intake and initiation (or not) of any nutritional intervention versus ONS only, were examined for the consistency of association with HAPI. Of the 5155 admissions during the study period, 895 patients fulfilled the inclusion criteria: 48% female, mean age 77.6±9.1 years, 11% with MUST score ≥2. Nutritional intake was reported in 76% of patients, of them 22% had low food intake, and 9% of the study group developed HAPI grade ≥2. Regarding HAPI incidence, no differences were found between groups divided by MUST scores. Independent risk factors significantly associated with HAPI were Norton <14, albumin levels <3g/dl, and low food intake. Not providing ONS in low food intake patients had an adjusted 3.49-fold (95%CI 1.57-7.75) increase in HAPI risk (6-fold for non-adjusted relative risk). Failure to initiate ONS as part of nutritional support in low food intake patients is associated with high HAPI risk in these patients. Consequently, monitoring of daily food intake for identifying low intake patients should be integrated into routinely used tools such as the Norton Scale, and adherence to nutritional protocols should be addressed.

Evidence-Based Approach to Decrease Incidence of Hospital-Acquired Pressure Injuries.

Hospital-acquired pressure injuries (HAPIs) are a painful and unwanted experience for the patient and cause unwanted additional costs to hospitals. Because HAPIs are a preventable occurrence, they are a nurse-sensitive indictor for national benchmarking when looking at quality and safety. Controlling the occurrence of HAPI in the hospital setting can be challenging for any nurse, but the difficulty is enhanced in the intensive care unit. This article discusses how a group of nurses from various areas of the hospital came together to heighten awareness of skin care and provided frontline education to peers. Through the use of structured programs using both a nationally known Wound Associate treatment program and Lean methodology, the nurses were able to work through processes and barriers and successfully decrease the incidence of HAPI in this academic medical center.

Air-Assisted Technology: A Quality Endeavor to Reduce Employee Injury and Hospital-Acquired Pressure Injuries.

Continuous quality improvement using Lean methodology engages and values the expertise of the staff close to the patient and the everyday work of caring for them. The patients are not safe if the staff is not safe. Finding the appropriate methodology, where the problem is deeply investigated, respect is visible in the process, and evidence-based decision-making takes place to find safe patient handling solutions for moving lifting and transferring patients was a key objective in this Lean process improvement effort. This article describes the journey taken, the collaboration of 2-unit based councils, and the successful implementation of an air-assisted moving, lifting, and transferring system at a large level 1 quaternary tertiary intercity hospital.

Predictive Ability of the Braden QD Scale for Hospital-Acquired Venous Thromboembolism in Hospitalized Children.

Hospital-acquired venous thromboembolisms (HA-VTEs) are increasingly common in pediatric inpatients and associated with significant morbidity and cost. The Braden QD Scale was created to predict the risk of hospital-acquired pressure injury (HAPI) and is used broadly in children's hospitals. This study evaluated the ability of the Braden QD Total score to predict risk of HA-VTE at a quaternary children's hospital. To analyze the predictive potential of the Braden QD Total score and subscores for HA-VTEs, the researchers performed univariate logistic regressions. The increase in a patient's odds of developing an HA-VTE for every 1-point increase in each Braden QD score was evaluated. Each model was evaluated using a 5-fold cross-validated area-under-the-curve of the corresponding receiver operating characteristic curve (AUROC). This study analyzed 27,689 pediatric inpatients. HA-VTE occurred in 135 patients. The odds of HA-VTE incidence increased by 29% (odds ratio 1.29, 95% confidence interval [CI] 1.25-1.34, p < 0.001) for every 1-point increase in a patient's Braden QD Total score. The AUROC was 0.81 (95% CI 0.77-0.85). The Braden QD Scale is a predictor for HA-VTE, outperforming its original intended use for predicting HAPI and performing similarly to other HA-VTE predictive models. As the Braden QD Total score is currently recorded in the electronic health records of many children's hospitals, it could be practically and easily implemented as a tool to predict which patients are at risk for HA-VTE.

Explainable Artificial Intelligence for Predicting Hospital-Acquired Pressure Injuries in COVID-19-Positive Critical Care Patients.

Alderden, Jenny PhD, APRN, CCRN, CCNS; Kennerly, Susan M. PhD, RN, WCC, FAAN; Wilson, Andrew PhD, MSTAT; Dimas, Jonathan PhD, RN, CCRN; McFarland, Casey BSN; Yap, David Y.; Zhao, Lucy PhD, RN; Yap, Tracey L. PhD, RN, WCC, FGSA, FAANEditor(s): Alexander, Susan DNP, ANP-BC, ADM-BC Author Information