Reduces Pressure Injury Research Articles

Reducing the Pressure: Improving the Safety of Adult Inpatients at an Urban Hospital by Reducing Pressure Injury Incidence

Background:Approximately 2.5 million hospital visits in the United States are due to pressure injuries (PIs), costing $11 billion and resulting in 60,000 deaths annually.Objective:The objective of the study is to decrease the incidence of PIs in a hospital setting using Situation, Background, Assessment, Recommendations, Wounds report sheets, turn clocks, and team engagement in a nurse-led quality improvement initiative.Methods:Four rapid Plan–Do–Study–Act cycles were implemented over 8 weeks. Aggregate data, run charts, staff feedback, and field notes were studied and guided new tests of change for each cycle.Results:The incidence of PIs decreased from a baseline of 40% to 17% over the 8-week period, which exceeded the goal of 20%. The average mean prevention score reached 74%, from a baseline of 45%. Skin assessment documentation increased from a baseline of 35% to 95%.Conclusions:The project was successful; the aim was exceeded through utilizing the best practice guidelines and toolkits, implementation of tools, and team participation. The project improved safety and communication while maintaining cost-effectiveness.Implications for Nursing:The Situation, Background, Assessment, Recommendations, Wounds (SBARW) and care audit tools can support the best practices to reduce PI incidence and show promise for improving quality nursing care.

Repositioning Guidelines to Decrease Pressure Injury in the Pediatric Intensive Care Unit: A Quality Improvement Project.

The purpose of this quality improvement (QI) project was to develop and implement repositioning guidelines that reduce pressure injury (PI) in hemodynamically unstable pediatric intensive care unit (PICU) patients. All PICU patient ages 0 to 36months who required sedation for invasive mechanical ventilation and had a Braden Q score≤18 were eligible for inclusion. The project was implemented in 116 patients preimplementation and 100 postimplementation. Their median t age was 5months (interquartile range 2-13months). The QI project setting was an academic hospital PICU with a Level I trauma center located in the Mid-Atlantic Region of the United States. A pre-post observational design was used to compare the at-risk population for 21weeks before (August-December 2018) and after (August-December 2019) implementing repositioning guidelines. Turn attempts were undertaken every 2hours. Repositioning attempts were defined as (1) full (30°); (2) partial (15°); (3) unable to turn owing to hemodynamic instability; or (4) noncompliance. The primary outcome was incidence of Stage II or higher PI. We found a significant reduction in the incidence of PI before and after implementation of the repositioning intervention (16.4% vs 2.0%, P =.0003). A structured intervention for repositioning hemodynamically unstable PICU patients has the potential to significantly lower PI incidence in a group of hemodynamically unstable children.

Reducing Pressure Injuries in a High-Risk Long-Term Acute Care Hospital

Reducing Pressure Injuries in a High-Risk Long-Term Acute Care Hospital

Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial.

Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care. This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence. For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care. Currently, 6 participants have been recruited for our aim-1 qualitative study. This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries. DERR1-10.2196/51849.

Effect of prophylactic dressings to reduce pressure injuries: a polymer-based skin model.

This study evaluated the effect of pressure injury (PI) prophylactic dressings used for patients at high risk of PI development to reduce friction, shear force and pressure, and their combined force, in an original polymer-based skin model. A low-friction outer-layer hydrocolloid (LFH) dressing and a multilayered silicone foam (MSF) dressing were used. Before application, compression and friction properties were measured. Our original experimental model-the 'simulated skin-shearing test'-consisted of: a weight; a polyurethane-based skin model containing a three-axis tactile sensor; dressings; a table covered with bedsheets; and a mechanical tester, by which the interface friction force, internal shear force and pressure were measured continuously during skin model movements. An estimated combined force generated by internal shear and pressure was represented as a vector. A model with no dressing was used as a control. The LFH dressing had significantly higher compression strength versus the MSF dressing. In contrast, the dynamic coefficient of friction was lower for the LFH dressing versus the MSF dressing (p<0.05). In simulated skin-shearing test results, shear forces were 0.45N and 0.42N for LFH and MSF dressings, respectively, with no significant difference. The estimated combined force was lower for the MSF dressing compared with that of the LFH dressing and control. The shear force-reducing effect in the skin model was equivalent between the LFH and MSF dressings. However, the MSF dressing significantly reduced the force generated by a combination of internal shear force and pressure compared with the LFH dressing.

Use of a novel pressure distribution system for severely ill neonates: a clinical pilot study carried out by the PREPICare consortium

BackgroundPressure Injuries are not exclusively an adult phenomenon; various risk factors contribute to a high prevalence rate of 43% in the neonatal and pediatric intensive care population. Effective preventive measures in this population are limited.MethodsWe performed a pilot study to analyze the distribution and localization of support surface interface pressures in neonates in a pediatric intensive care unit (PICU). The hypothesis was that pressure redistribution by a novel air mattress would reduce pressure peaks in critical neonates. The measurements were conducted in a 27-bed level III PICU between November and December 2020. This included measuring pressure distribution and pressure peaks for five neonates positioned on either a state-of-the-art foam mattress or a new prototype air mattress.ResultsWe confirmed that the pressure peaks were significantly reduced using the prototype air mattress, compared with the state-of-the-art foam mattress. The reduction of mean pressure values was 9–29%, while the reduction of the highest 10% of pressure values was 23–41%.ConclusionsThe journey to an effective, optimal, and approved product for severely ill neonates to reduce Pressure Injuries is challenging. However, a crucial step was completed by this pilot study with the first pressure measurements in a real-world setting and the successful realization of a decrease in pressure peaks obtained using a prototype air mattress.

OFF-LOADING PRESSURE RELIEF WITH FOAM CUT OUT CUSHIONS: EXPERIENCES FROM RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER.

This paper explores the efficacy of the cushion fitting technique using foam cut out cushions for off-loading bony prominences in the sitting position, with a particular focus on reducing the high risk of developing pressure injuries among aging wheelchair users. This technique, historically employed at Rancho Los Amigos National Rehabilitation Center, has shown promising results in reducing pressure injuries for patients with spinal cord injuries. However, its widespread adoption remains limited. This manuscript aims to raise awareness about foam cut out cushions, its historical context, and its contemporary relevance by presenting customized solutions for individual patients with specific deformities. Key clinical points are highlighted, emphasizing the importance of skilled clinicians in the fitting process and the need to consider foam cut out cushions alongside other preventive measures. Case examples illustrate successful outcomes, demonstrating improved pelvic stability, posture, and off-loading of bony prominences. By promoting foam cut out cushions as a valuable cushioning option, this manuscript equips clinicians with knowledge to utilize this technique effectively.

Reducing Pressure Injuries Within the Perioperative Oncology Setting Using an Evidence-Based Quality Improvement Initiative.

Surgical patients with cancer are at high risk for developing operating room-related hospital-acquired pressure injuries (OR-HAPIs). A nurse-led team at a Magnet-designated comprehensive cancer center was tasked with implem.

The effects of educational intervention on patient participation in pressure injury prevention: a pilot study.

Patients' roles in reducing pressure injuries (PIs) are emphasised in clinical guidelines, although patients' preferences are undetermined. This study evaluated the effects of a pilot six-month educational intervention on patient participation in PI prevention. A convenience sampling method was used to select patients admitted to medical-surgical wards at one of the teaching hospitals in Tabriz, Iran. This is a one-group pre-test and post-test interventional study, conducted via quasi-experimental design. Using a pamphlet, patients received education in preventing PIs. Data collected before and after intervention through a questionnaire were analysed using descriptive and inferential statistics (McNemar and paired t-tests) in SPSS software (IBM Corp., US). The study cohort consisted of 153 patients. Findings revealed that the knowledge of the patients about PIs, patients' ability to talk with the nurses, information received about PIs, and patients' ability to participate in decisions related to PI prevention had significantly increased following the intervention (p<0.001). Educating patients can improve their knowledge to enable them to participate in PI prevention. The findings of this study suggests further research is necessary on factors influencing patients' participation in such self-care behaviours.

Upright vs. supine shape-capturing comparison for custom-contoured cushions

AimsThis study aims to explore best practices of shape capturing methods for creating custom-contoured wheelchair cushions for the purpose of reducing pressure injury risk. Materials and methodsPressure redistribution qualities were measured by peak pressure index (PPI) and compared between custom-contoured seating systems molded in supine vs. upright shape-capturing positions. Subjects consisted of 14 able-bodied participants in a within-subjects comparison. ResultsA Wilcoxon signed-rank test and paired t-test were calculated to compare the mean differences of the PPI between shape-capturing positions. Supine shape-capturing resulted in a statistically significant lower PPI compared to upright (z = 2.040, p < . 05) (t = −2.28, p < .05). ConclusionShape-capturing in the supine position provided greater pressure distribution as opposed to an upright position. Creating custom-contoured cushions molded in a supine position can reduce the risk of pressure injury to the patient.

Determining frictional properties of pants and cushion cover materials using human soft tissue and a rigid sled and how they affect seated shear forces

Shear forces on the buttocks while seated are directly linked to friction, yet the frictional properties at the seat interface are unknown. Shear forces are one of the factors related to increase risk of pressure injury formation. The goals of this study included determining coefficients of friction between three cushion covers and two clothing fabrics using a mechanical system as well as human participants and to evaluate the impact of the cushion covers on shear loading on the buttocks while seated. A chair with separate seat pan tilt and back recline movements was built and instrumented with reflective markers and a load cell. A motion capture system and load cell were used to determine the angles of seat pan tilt at which the sled and participants started sliding, as well as shear forces at three recline angles for three cushion covers (vinyl, one-layer nylon, and two-layer nylon). Results showed the vinyl and two-layer nylon cushion covers respectively had the largest and smallest coefficients of friction for both pants materials. The coefficients of friction calculated with the human participants and rigid sled were within 10% of each other, demonstrating similar results. Further, increasing back recline increased shear load on the buttocks, while the two-layer nylon cover reduced shear forces seen on the buttocks. This work furthers the understanding of shear loading on the buttocks, will aid in the protocols for reducing pressure injuries, and suggests that coefficients of friction found using rigid bodies may be applied to deformable bodies.

Determining Incidence and Risk Factors of Pressure Injury After Orthopaedic Surgery in Children and Adolescents With Neuromuscular Complex Chronic Conditions.

Pressure injuries are serious yet often preventable alterations in skin integrity prevalent in orthopaedics, especially in pediatric patients with neuromuscular complex chronic conditions (NCCC). The aims of this study were to (1) estimate incidence of pressure injury in children with NCCC after orthopaedic surgery; (2) determine risk factors for pressure injury development; and (3) describe severity and location of pressure injuries. Children and adolescents (<22y old) with NCCC who underwent orthopaedic surgery at a single tertiary-care children's hospital between 2016 and 2020 were retrospectively identified. A matched case-control design was used to match patients who developed a pressure injury within 1.5 months after surgery to subjects who did not develop a pressure injury using a 1:1 matching based on neuromuscular diagnosis, age, sex, and type of surgery. Patient characteristics, comorbidities, pressure injury characteristics, and a pressure injury risk assessment score utilizing the Braden QD scale were compared across pressure injury groups. Of 564 children with NCCC who underwent orthopaedic surgery, 43 (7.6%) developed a postoperative pressure injury. Pressure injuries were primarily located on the heel, followed by sacral/groin/buttocks, then knee. The most common diagnosis was cerebral palsy with associated neuromuscular scoliosis, and hip reconstruction was the most common surgical procedure. The pressure injury cohort had significantly more patients who were non-ambulatory (GMFCS IV/V), with a seizure disorder, g-tube, nonverbal status, wheelchair usage, and had additional medical devices. Median Braden QD risk score was higher in the injury cohort and a cutoff ≥12 was optimal for predicting pressure injury development. Pressure injuries after orthopaedic surgery are not uncommon in children with NCCC. The entire care team should be aware of additional risk factors associated with pressure injury development, including the diagnosis of cerebral palsy with neuromuscular scoliosis, seizure disorder, nonverbal status, g-tube, and the presence of multiple medical devices. Implementation of evidence-based pressure injury prevention guidelines on identified high-risk children with NCCC may reduce pressure injury risk and improve the postoperative course. Level III.

Evaluating the Efficacy of a New Alternating Pressure Air Mattress Aimed at Reducing Pressure Injuries During the Transport of Combat Casualties.

The development of pressure ulcers during aeromedical transport of combat casualties is an issue that continues to exist, especially during long transport flights. This study investigated the potential for a new intervention, an air-inflated insulating mattress pad (IMP) that has a pump system designed to alternate the pressurization of air cells under the patient, thus temporally shifting the pressure concentration locations. In a repeated measures design study, 12 participants experienced the following four simulated transport conditions, each for 90 minutes: (1) The North Atlantic Treaty Organization (NATO) litter by itself (control condition), (2) the NATO litter covered with the standard mattress pad (Warrior Evacuation Pad), (3) the NATO litter covered with the air-inflated mattress (IMP), and (4) the NATO litter, covered with the standard mattress pad that was covered by the insulating mattress pad. Peak pressure readings were obtained every 15 seconds under the head, torso, pelvis, legs, and heels. While both mattress pads significantly reduced the peak pressures relative to the litter-only condition, the new IMP with the alternating cell pressurizations, by itself or in combination with the standard mattress pad, further reduced the peak pressures under the regions with the localized highest pressures, namely the head, pelvis, and heels. Moreover, the IMP with alternating pressure introduced the most variability in the peak pressure readings, which reduces the peak pressure exposure periods for specific tissue locations. The IMP with alternating cell pressurizations could further reduce the likelihood of pressure injuries during aeromedical transport of combat casualties.

Reducing pressure injuries in children caused by peripheral intravenous cannulae.

Medical devices such as peripheral intravenous cannulae (PIVC) are commonly used in the care of children across all hospital settings. However, the association between PIVC and the development of pressure injuries in this population became a concern on one Australian paediatric ward. A quality improvement project was conducted to reduce the incidence of pressure injuries in children caused by PIVCs. A tubular bandage and microfoam surgical tape were introduced to replace crepe bandage PIVC securement. At the same time, education was provided to alert nurses to medical device-related pressure injuries and the PIVC securement changes. The introduction of the tubular bandage and staff education improved skin inspections of PIVCs and decreased the incidence of pressure injuries from these devices.

Quality Improvement Intervention Bundle Using the PUPPIES Acronym Reduces Pressure Injury Incidence in Critically Ill Patients.

To assess whether a quality improvement bundle focusing on prevention is effective in reducing pressure injury (PI) incidence or costs or delaying PI onset. A combined retrospective/prospective cohort study was performed at an academic tertiary care ICU on all patients admitted with a length of stay longer than 48 hours and Braden scale score of 18 or less. Following retrospective data collection (preintervention), a multimodal quality improvement bundle focusing on PI prevention through leadership initiatives, visual tools, and staff/patient education was developed, and data were prospectively collected (postintervention). Statistical and cost analyses were performed comparing both cohorts. A total of 930 patients met the study inclusion criteria (preintervention, n = 599; postintervention, n = 331). A significant decrease in PI incidence was observed from preintervention (n = 37 [6%]) to postintervention (n = 7 [2%], P = .005). This led to a predicted yearly cost savings of $826,810. Further, a significant increase in time to PI occurrence was observed from preintervention (mean, 5 days) to postintervention (mean, 9 days; P = .04). Staff were compliant with the bundle implementation 80% of the time. Implementation of the quality improvement bundle focused on multimodal PI prevention in critically ill patients led to a significant reduction in PI incidence, increased time to PI occurrence, and was cost-effective.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Shifting loads as a result of chair articulations and associated perfusion responses in the context of pressure injuries: An investigation with able-bodied individuals

Wheelchair users with spinal cord injuries experience pressure injuries at high rates, causing a decrease in quality of life and an increased financial burden. The soft tissue in the buttocks (beneath the ischial tuberosities) and lower back (behind the sacrum) experience large interface pressures over long periods while seated, putting them at high risk of pressure injury development. The goals of this research were to evaluate the ability of an articulating chair design to redistribute pressures on the body and to affect blood perfusion in the buttocks tissue over the ischial tuberosities. Using a unique, custom-designed chair developed for this research, pressure and blood perfusion were obtained for numerous seated positions that included recline, seat pan tilt, and back articulations. Reclining the chair back increased maximum pressures in the buttocks and lower back regions, while it decreased maximum pressures in the upper back and thigh regions. Increasing seat pan tilt, or rotating the anterior edge of the seat pan above the posterior edge, decreased maximum pressures in the buttocks and lower back regions and increased perfusion in the buttocks. Results suggested that using back recline and seat pan tilt together to create a whole-body tilt increased pressures in the back and decreased pressures in the buttocks. Changes in back articulation redistributed pressure in all back regions. Thus, the articulating chair design redistributed pressures in all areas of the body and promoted blood perfusion in the buttocks while seated. Pressure redistribution and perfusion promotion are fundamental to reducing pressure injury risk.

Educating Certified Nursing Assistants to Communicate Skin Changes to Reduce Pressure Injuries.

Pressure injuries (PIs) are common and costly complications in long-term care (LTC) residents. Educating and coaching certified nursing assistants (CNAs) to communicate early skin changes is a PI surveillance strategy that may influence PI outcomes. A communication guide related to Skin, Clean, Activity, and Nutrition was developed for CNAs to promote prompt upstream communication to licensed nurses. A pre-/post-intervention design measured PI knowledge and skills in 24 CNAs, and PI incidence was tracked over a 6-week time period. CNAs demonstrated improvement in their PI surveillance role, comfort in identifying and reporting skin changes, keeping skin clean and dry, and resident nutritional status. Baseline PI incidence of 9.6% decreased to 0% by Week 3, and no new PIs occurred over 6 weeks. CNAs developed role awareness and knowledge in primary PI surveillance and were instrumental in a team approach to decrease PIs in a LTC setting. [Journal of Gerontological Nursing, 47(8), 21-28.].

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BackgroundPressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit. ObjectivesThe objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations. MethodsA prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1–18; period 2, weeks 19–28; and period 3, weeks 29–52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist. ResultsOver the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20–0.97, p = 0.0126). ConclusionsWe found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

P0525 / #423: REPOSITIONING GUIDELINES TO DECREASE PRESSURE INJURIES IN THE PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: Objectives: Critically ill patients in the PICU are at risk of pressure injury (PI), particularly when hemodynamic instability is a barrier to repositioning. The objective of this project was to create evidence-based repositioning guidelines for hemodynamically unstable PICU patients and test the effectiveness of guideline implementation on PI incidence. Methods: Methods: A pre-post observational design was used for the QI project, comparing the at risk population for 21 weeks before guideline implementation (August 2018-January 2019) and for 21 weeks post-implementation (August 2019-January 2020). PICU nurses completed surveys to identify barriers to intervention and an interdisciplinary consensus panel developed guidelines for repositioning hemodynamically unstable patients. All PICU patients age 0 to 36 months sedated for invasive mechanical ventilation with a Braden Q score ≤ 18 were eligible for inclusion. Repositioning was measured every 2 hours; full turn (300), partial turn (150), unable to turn due to hemodynamic instability or noncompliance. The primary outcome was incidence of Stage II or higher PI. Results: Results: Pre-implementation survey data revealed 16.4% of nurses (n=68 respondents) identified confidence in identification of hemodynamic instability parameters. In the pre-implementation period, 19 of 116 (15%) patients developed PI compared to 2 of 100 (2%) patients after implementation of the repositioning guidelines (p<0.001). The anatomical location of PI pre-implementation was occipital (68%), device related (27%) and heel (5%). Post-implementation identified occipital (50%) and device related (50%). Conclusions: Conclusions: A standard methodology for repositioning hemodynamically unstable PICU patients reduces pressure injury. New measurement of compliance provides an accurate and specific description of repositioning.