Risk Factors Associated With Pressure Ulcer Formation in Critically Ill Cardiac Surgery Patients: A Systematic Review.

BACKGROUND: Cardiac surgery patients are among those most at risk for developing pressure ulcers (PUs), with a reported incidence as high as 29.5%. Although numerous studies documenting PU risk factors and prevention strategies exist, the availability of literature examining risk factors specific to the cardiac surgery population is limited. AIM: A systematic review was completed that aimed to identify the risk factors associated with PU development in critically ill, adult, cardiac surgery patients. METHODS: The MEDLINE, CINAHL, and Cochrane databases were searched. Studies that focused on PU risk factors in critical care, surgical intensive care, or cardiac surgery populations and used PU occurrences as an outcome variable were included in the review. FINDINGS: Twelve high-quality studies were retrieved and included in the review; they revealed 30 potential PU risk factors. Current evidence is limited in 2 important ways. First, the impact of intraoperative factors, such as cardiopulmonary bypass time or body temperature, appears to be underexplored. Second, a substantive discussion of the risk factors associated specifically with deep tissue injuries, a unique PU category, is absent. CONCLUSION: The relatively high PU incidence among cardiac surgery patients suggests that typical PU prevention methods are insufficient for this population. Targeted prevention measures must be developed and implemented. Completion of this task required identification of risk factors unique to this population. Specific risk factors likely to increase risk among cardiac surgery patients include prolonged exposure to pressure during long surgical procedures, vascular disease, and/or vasopressor use postoperatively. Additional research concerning risk factors specific to this population is urgently needed.

Is One-Pen, One-Patient Achievable in the Hospital? A Quality Improvement Project to Reduce Risks of Inadvertent Insulin Pen Sharing at a Large Academic Medical Center.

BACKGROUND: The Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and Institute for Safe Medicine Practices (ISMP) have issued warnings regarding the risk of potential transmission of blood-borne diseases if an insulin pen is used for more than one person. Many hospitals continue to use insulin pens due to their benefits of decreased risk of dosing error and improved work efficiency. Best practices for insulin pen use have been published; however, little is known about how these perform in hospitals. METHODS: This article describes a multifaceted quality improvement project to address the safety issues of single-patient insulin pens. Major interventions included adding patient-specific bar coding on insulin pens, redesign of labels, systematic removal of discharged patients' medications, and ongoing staff education. RESULTS: Self-reported events of insulin pen sharing events over 40 months showed a significant increase in the number of patient-days between events. The significant change occurred after implementation of patient-specific bar code scanning. There was a gradual decrease in latent errors found during medication drawer audits, and nursing compliance with patient-specific bar code scanning improved over time, reaching 90% on the last recorded month. Of 35 expert recommendations for insulin pen safety, 28 directly affected pen sharing-8 had been implemented prior to this project, and 20 had been implemented by the conclusion. CONCLUSION: Insulin pen use is highly complex in hospital settings where multiple steps provide opportunities for error. To protect patients, all gaps need to be reviewed, and interventions that address major contributing factors are required to ensure safe insulin pen use.

Theory of nonlinear creep in polymer glasses.

A statistical segment-scale constitutive equation theory for the nonlinear mechanics and relaxation of polymer glasses recently proposed by two of us is applied to study nonlinear creep and recovery. The key physics resides in a deformation-dependent elastic modulus and alpha relaxation time, which are determined by a segment-displacement-dependent dynamical free energy that quantifies the transient localization and activated hopping processes. For simple creep and recovery, the amplitudes of the instantaneous up- and down strain jumps are equal and exhibit upward deviations from a linear dependence on applied stress due to modulus softening. Nonexponential relaxation indicative of a distribution of alpha relaxation times is incorporated and shown to be crucial in determining the so-called delayed elastic deformation at intermediate times. The amount of delayed recovered strain appears to saturate at long times at a value equal to the total delayed elastic deformation during creep. Calculations of the time-dependent creep compliance covering the linear and nonlinear regimes are presented. Horizontal shifts can collapse the compliance curves at different stress levels onto a master plot as seen experimentally, and the extracted shift factor quantitatively agrees with the a priori computed normalized alpha relaxation time. Calculations for two-step creep at small stress are in reasonable agreement with experiments on poly(methylmethacrylate) glass, although systematic deviations occur at very high applied stresses.

Deep Tissue Pressure Injury: A Clinical Review.

: A deep tissue pressure injury (DTPI) is a serious type of pressure injury that begins in the muscle closest to the bone and may not be visible in its early stages. Its hallmark is rapid deterioration despite the use of appropriate preventive interventions. In 2007, the National Pressure Ulcer Advisory Panel added suspected deep tissue injuries to the traditional classification system, and by 2010 DTPIs had accounted for about 9% of all pressure injuries and were for the first time more prevalent than stage 3 or 4 pressure injuries. On average, patients who develop these injuries are older and have a lower body mass index than patients who develop other pressure injuries. Most commonly, DTPIs appear on the skin over the coccyx or sacrum, the buttocks, and the heels. This article discusses the pathophysiology; risk factors; and assessment, prevention, and treatment of DTPIs, using a composite case to illustrate the progression of this serious type of pressure injury.