WHS guidelines for the treatment of pressure ulcers-2023 update.

The major populations at risk for developing pressure ulcers are older adults who have multiple risk factors that increase their vulnerability, people who are critically ill and those with spinal cord injury/disease. The reported prevalence of pressure ulcers in the United States is 2.5 million. However, this estimate is derived from acute care facilities and does not include people who are living at home or in nursing facilities. Despite the implementation of hospital and facility-based preventive measures, the incidence of pressure ulcers has not decreased in decades. In addition to the burden of pain, infection and death, it is estimated that hospital-acquired pressure ulcers cost the health system $26.8 billion annually with over 50% of the cost attributed to treating Stage 3 and 4 pressure injuries. Thus, it is critical to examine the literature and develop guidelines that will improve the outcomes of this complex and costly condition. This guideline update is a compendium of the best available evidence for the treatment of Pressure Ulcers published since the last update in 2015 and includes a new section based on changing demographics entitled 'Palliative wound care for seriously ill patients with pressure ulcers'. The overall goal of the Wound Healing Society Guideline project is to present clear, concise and commercial free guidelines that clinicians can use to guide care, that researchers can use to develop studies that will improve treatment and that both clinicians and researchers can use to understand the gaps in our knowledge base.

Movement and Pressure Injury Prevention Care for Nursing Home Residents: Addressing the Nescience.

OBJECTIVE: To compare movement associated with position changes among nursing home residents who remain in lying versus upright positions for more than 2 hours and among residents living with obesity, dementia, or neither condition. METHODS: The authors conducted a descriptive exploratory study using secondary data (N = 934) from the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) clinical trial to examine transient movements (<60 seconds) within prolonged periods of 2 to 5 hours without repositioning. RESULTS: Nursing home residents exhibit significantly more episodic transient movements when upright than lying. Residents with obesity or dementia exhibited similar frequencies of episodic transient movements compared with residents with neither obesity nor dementia. Upright or lying movements were more frequent among residents with obesity than among those with neither obesity nor dementia selectively when prolonged events ranged from 2 to 4 hours. Pairwise comparisons of movement rates among resident subgroups (living with obesity, living with dementia, or neither group) across repositioning intervals showed episodic transient movements were significantly higher across all subgroups for repositioning intervals up to 3 hours when compared with repositioning intervals of greater than 3 hours. CONCLUSIONS: Findings challenge assumptions that nursing home residents are inactive and at risk for prolonged sitting. These preliminary findings, along with TEAM-UP findings where no pressure injuries occurred in up to 5 hours in prolonged positions, support establishing a standard 3-hour repositioning interval with use of high-density mattresses without a negative impact on pressure injury occurrence. There should be caution when considering repositioning intervals greater than 3 hours. Further research is indicated to explore protective effect of episodic transient movements of other subgroups.

Estimating the value of repositioning timing to streamline pressure injury prevention efforts in nursing homes: A cost-effectiveness analysis of the 'TEAM-UP' clinical trial.

Pressure injury (PrI) prevention guidelines recommend 2-h repositioning intervals in healthcare settings, requiring significant nursing time investment. We analysed the cost-effectiveness of PrI prevention protocols with 2-, 3- and 4-h repositioning intervals in US nursing homes according to 'Turn Everyone and Move for Ulcer Prevention' (TEAM-UP) randomized controlled trial findings. Markov modelling compared 2-, 3- and 4-h repositioning intervals, controlling for other practice guidelines, to prevent PrIs in nursing home residents from a US health sector perspective over one year using TEAM-UP trial data for model structure, sampling and parameterization. Costs, captured in 2020 US dollars, and quality-adjusted life years (QALYs) were used to derive an incremental cost-effectiveness ratio and net monetary benefit (NMB) at $50 000/QALY-$150 000/QALY cost-effectiveness thresholds. Sensitivity analyses tested model uncertainty. Repositioning intervals between 3 and 4 h were cost-effective based on reduced costs at slightly lower QALYs than 2 h at a $50 000/QALY threshold, and the NMB of 4-h repositioning was also more efficient than at 3 h ($9610). Repositioning labour cost and prevention routines were among the most sensitive parameters. Sensitivity analyses demonstrated that 3- and 4-h intervals were cost-effective in over 65% of simulations at any cost-effectiveness threshold. Repositioning intervals of 3 to 4 h have potential to reduce nursing time costs without significant decrements in clinical benefits to nursing home residents. Clinical guidelines for PrI prevention should be updated to reflect TEAM-UP clinical and economic findings. Facilities can use cost-savings recuperated from nursing time to deploy to other patient safety priorities without seriously jeopardizing PrI safety.

Characteristics of Nursing Home Resident Movement Patterns: Results from the TEAM-UP Trial.

OBJECTIVE: To determine movement patterns of nursing home residents, specifically those with dementia or obesity, to improve repositioning approaches to pressure injury (PrI) prevention. METHODS: A descriptive exploratory study was conducted using secondary data from the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) clinical trial examining PrI prevention repositioning intervals. K-means cluster analysis used the average of each resident's multiple days' observations of four summary mean daily variables to create homogeneous movement pattern clusters. Growth mixture models examined movement pattern changes over time. Logistic regression analyses predicted resident and nursing home cluster group membership. RESULTS: Three optimal clusters partitioned 913 residents into mutually exclusive groups with significantly different upright and lying patterns. The models indicated stable movement pattern trajectories across the 28-day intervention period. Cluster profiles were not differentiated by residents with dementia (n = 450) or obesity (n = 285) diagnosis; significant cluster differences were associated with age and Braden Scale total scores or risk categories. Within clusters 2 and 3, residents with dementia were older (P < .0001) and, in cluster 2, were also at greater PrI risk (P < .0001) compared with residents with obesity; neither group differed in cluster 1. CONCLUSIONS: Study results determined three movement pattern clusters and advanced understanding of the effects of dementia and obesity on movement with the potential to improve repositioning protocols for more effective PrI prevention. Lying and upright position frequencies and durations provide foundational knowledge to support tailoring of PrI prevention interventions despite few significant differences in repositioning patterns for residents with dementia or obesity.

Movement Patterns of Transient and Prolonged Positioning Events in Nursing Home Residents: Results from the TEAM-UP Trial.

OBJECTIVE: To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence. METHODS: This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift. RESULTS: Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased. CONCLUSIONS: The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results.

OBJECTIVE: To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks. METHODS: An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity. RESULTS: From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P < .001). CONCLUSIONS: Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

Hospital acquired pressure injury prediction in surgical critical care patients.

BACKGROUND: Hospital-acquired pressure injuries (HAPrIs) are areas of damage to the skin occurring among 5-10% of surgical intensive care unit (ICU) patients. HAPrIs are mostly preventable; however, prevention may require measures not feasible for every patient because of the cost or intensity of nursing care. Therefore, recommended standards of practice include HAPrI risk assessment at routine intervals. However, no HAPrI risk-prediction tools demonstrate adequate predictive validity in the ICU population. The purpose of the current study was to develop and compare models predicting HAPrIs among surgical ICU patients using electronic health record (EHR) data. METHODS: In this retrospective cohort study, we obtained data for patients admitted to the surgical ICU or cardiovascular surgical ICU between 2014 and 2018 via query of our institution's EHR. We developed predictive models utilizing three sets of variables: (1) variables obtained during routine care + the Braden Scale (a pressure-injury risk-assessment scale); (2) routine care only; and (3) a parsimonious set of five routine-care variables chosen based on availability from an EHR and data warehouse perspective. Aiming to select the best model for predicting HAPrIs, we split each data set into standard 80:20 train:test sets and applied five classification algorithms. We performed this process on each of the three data sets, evaluating model performance based on continuous performance on the receiver operating characteristic curve and the F1 score. RESULTS: Among 5,101 patients included in analysis, 333 (6.5%) developed a HAPrI. F1 scores of the five classification algorithms proved to be a valuable evaluation metric for model performance considering the class imbalance. Models developed with the parsimonious data set had comparable F1 scores to those developed with the larger set of predictor variables. CONCLUSIONS: Results from this study show the feasibility of using EHR data for accurately predicting HAPrIs and that good performance can be found with a small group of easily accessible predictor variables. Future study is needed to test the models in an external sample.

Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report.

ABSTRACT: Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

Subsequent Pressure Injury Development in Mechanically Ventilated Critical Care Patients with Hospital-Acquired Pressure Injury: A Retrospective Cohort Study.

OBJECTIVE: To identify factors associated with subsequent hospital-acquired pressure injury (HAPrI) formation among patients in surgical and cardiovascular surgical ICUs with an initial HAPrI. METHODS: Patients admitted to a level 1 trauma center and academic medical center in the Western US between 2014 and 2018 were eligible for this retrospective cohort study. Inclusion criteria were development of an HAPrI stage 2 or above, age older than 18 years, the use of mechanical ventilation for at least 24 hours, and documentation of a risk-based HAPrI-prevention plan including repositioning at least every 2 hours. The primary outcome measure was development of a second, subsequent HAPrI stage 2 or higher. Potential predictor variables included demographic factors, shock, Charleston comorbidity score, blood gas and laboratory values, surgical factors, vasopressor infusions, levels of sedation or agitation, Braden Scale scores, and nursing skin assessment data. RESULTS: The final sample consisted of 226 patients. Among those, 77 (34%) developed a second HAPrI. Independent risk factors for subsequent HAPrI formation were decreased hemoglobin (odds ratio, 0.71; 95% confidence interval [CI], 0.53-0.92; P < .000), vasopressin infusion (odds ratio, 2.20; 95% CI, 1.17-4.26; P = .02), and longer length of stay in the ICU (odds ratio, 1.01; 95% CI, 1.00-1.02; P = .009). CONCLUSIONS: Patients with an HAPrI are at high risk of subsequent HAPrI development. Anemia, vasopressin infusion, and longer ICU stays are independent risk factors for repeat HAPrI formation.

Hospital-Acquired Pressure Injury Development Among Surgical Critical Care Patients Admitted With Community-Acquired Pressure Injury: A Retrospective Cohort Study.

PURPOSE: Community-acquired pressure injuries (CAPIs) are present among approximately 3% to 8% of patients admitted to acute care hospitals. In the critical care population, little is known about hospital-acquired pressure injury (HAPI) development among patients with CAPIs because most studies exclude patients with CAPIs. The purpose of our study was to determine the incidence of HAPI development and the associated risk factors among surgical critical care patients with CAPIs. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: We used electronic health record data from adult critical care patients admitted to the surgical and cardiovascular surgical intensive care units (ICUs) at a level 1 trauma center and academic medical center between 2014 and 2018. METHODS: Univariate analysis was used to compare patients with CAPIs who developed a HAPI and those who did not, as well as logistic regression analysis to identify independent risk factors for HAPIs among patients with CAPIs. RESULTS: Among 5101 patients admitted to 2 surgical critical care units, 167 (3%) patients were admitted with CAPIs. Hospital-acquired pressure injuries were 4 times more common among patients with CAPIs compared to patients without CAPIs. Among the 167 patients with CAPIs, 47 patients (28%) went on to also develop a HAPI, whereas in the 4934 patients without CAPIs, 352 patients (7%) went on to develop a HAPI. Findings from the multivariate logistic regression analysis (n = 151) showed that decreased serum albumin (odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.25-0.85; P = .02) and excessively dry skin (OR = 2.6; 95% CI, 1.1-6.22; P = .03) were independent predictors of HAPI development among patients admitted with CAPIs. CONCLUSIONS: Results from our study show that patients with CAPIs are at high risk for developing a HAPI, particularly among patients with decreased serum albumin or excessively dry skin. Patients with excessively dry skin may benefit from the application of skin moisturizers.

Influence of Nutrition and Nonnutrition Factors on Pressure Injury Outcomes Among At-Risk Asian Nursing Home Residents.

OBJECTIVE: Given evidence that malnutrition and immobility increase the risk of pressure injuries (PIs) in nursing home (NH) residents and that body mass index guidelines related to undernutrition may differ between Asian and non-Asian populations, the purpose of this study was to describe differences in overall nutrition, dietary intake, and nonnutrition risk factors for PIs between Asian and non-Asian NH residents. DESIGN AND SETTING: Secondary data analysis of a 3-week PI prevention randomized controlled trial in seven Canadian NHs. PATIENTS: Asian (n = 97) and non-Asian (n = 408) residents at moderate or high mobility-related risk of PI. MAIN OUTCOME MEASURE: Incident PI by racial subgroups. MAIN RESULTS: Asian residents (PI = 6) consumed significantly smaller meals and marginally different patterns of daily dietary consumption of protein types, liquid supplements, and snacks; took more frequent tub baths; and had marginally lower body mass index than non-Asian residents (PI = 4). CONCLUSIONS: Findings are consistent with earlier research suggesting that nutrition consumption and care patterns may predispose Asian NH residents to develop more PIs than their non-Asian counterparts. Future research should focus on the threshold for and types of nutrition support sufficient to improve nutrition status and reduce PI risk.

Pressure Injury Prevention: Outcomes and Challenges to Use of Resident Monitoring Technology in a Nursing Home.

PURPOSE: We examined the usability, user perceptions, and nursing occupational subculture associated with introduction of a patient monitoring system to facilitate nursing staff implementation of standard care for pressure ulcer/injury prevention in the nursing home setting. DESIGN: Mixed methods, pre-/posttest design. SUBJECTS AND SETTING: Resident (n = 44) and staff (n = 38) participants were recruited from a 120-bed nursing home in the Southeast United States. METHODS: Digital data on frequency and position of residents were transmitted wirelessly from sensors worn on each resident's anterior chest to estimate nursing staff compliance with repositioning standard of care before and after visual monitors were activated to cue staff. The validated Nursing Culture Assessment Tool was used to determine changes in nursing culture. Benefits and challenges of implementation were assessed by 2 focus groups composed of 8 and 5 female members of the nursing staff (RN, LPN, CNA), respectively, and led by the three authors. Descriptive statistics were used for all quantitative variables, and inferential statistics were applied to categorical variables (χ test or Fisher exact test) and continuous variables (analyses of variance or equivalent nonparametric tests), respectively, where a 2-sided P value of <.05 was considered statistically significant. RESULTS: System use significantly (P = .0003) improved compliance with every 2-hour repositioning standards. The nursing culture normative ranking percentage increased from 30.9% to 58.2%; this difference was not statistically significant. Focus groups expressed satisfaction with the monitoring system and recommended improvements to support adaptation and use of technology. CONCLUSIONS: Study findings support the usability of the patient monitoring system to facilitate repositioning. Implementation of multiple strategies for training, supplies, and communication may enhance uptake and effectiveness.

Changing Team Member Perceptions by Implementing TeamSTEPPS in an Emergency Department.

INTRODUCTION: The emergency department is an environment where teamwork and communication are of utmost importance and are the foundation for improved patient satisfaction, staff satisfaction, patient safety, and the reduction of clinical errors. An ED staff perceptions of communication and teamwork influences their ability to provide efficient, high quality care to patients. METHODS: The ED team consisted of 57 employees, including nurses, mid-level providers, and non-licensed individuals, who work within, or directly with, the department. This quality improvement project trained 57 members of the ED staff using the TeamSTEPPS training program. Forty-six of the participants completed assessments at all 3 time points (baseline, 2 weeks and one month): Team STEPPS Teamwork Perceptions and Attitudes Questionnaires and The Nursing Culture Assessment Tool (NCAT). RESULTS: Formal group TeamSTEPPS training improved the emergency department team members' perceptions of, and attitudes about, communication and teamwork. DISCUSSION: As a result of TeamSTEPPS training in an Emergency Department, the staff of that department perceived that both teamwork and communication improved. The TeamSTEPPs program should be made sustainable by incorporating the verbiage and tools from the program into policy and culture within the department.

TEAM-UP for quality: a cluster randomized controlled trial protocol focused on preventing pressure ulcers through repositioning frequency and precipitating factors.

BACKGROUND: Pressure ulcers/injuries (PrUs), a critical concern for nursing homes (NH), are responsible for chronic wounds, amputations, septic infections, and premature deaths. PrUs occur most commonly in older adults and NH residence is a risk factor for their development, with at least one of every nine U.S. NH residents experiencing a PrU and many NHs having high incidence and prevalence rates, in some instances well over 20%. PrU direct treatment costs are greater than prevention costs, making prevention-focused protocols critical. Current PrU prevention protocols recommend repositioning residents at moderate, high, and severe risk every 2 h. The advent of visco-elastic (VE) high-density foam support-surfaces over the past decade may now make it possible to extend the repositioning interval to every 3 or 4 h without increasing PrU development. The TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study aims to determine: 1) whether repositioning interval can be extended for NH residents without compromising PrU incidence and 2) how changes in medical severity interact with changes in risk level and repositioning schedule to predict PrU development. METHODS: In this proposed cluster randomized study, 9 NHs will be randomly assigned to one of three repositioning intervals (2, 3, or 4 h) for a 4-week period. Each enrolled site will use a single NH-wide repositioning interval as the standard of care for residents at low, moderate, and high risk of PrU development (N = 951) meeting the following criteria: minimum 3-day stay, without PrUs, no adhesive allergy, and using VE support surfaces (mattresses). An FDA-cleared patient monitoring system that records position/movement of these residents via individual wireless sensors will be used to visually cue staff when residents need repositioning and document compliance with repositioning protocols. DISCUSSION: This study will advance knowledge about repositioning frequency and clinically assessed PrU risk level in relation to PrU incidence and medical severity. Outcomes of this research will contribute to future guidelines for more precise preventive nursing practices and refinement of PrU prevention guidelines. TRIAL REGISTRATION: Clinical Trial Registration: NCT02996331 .

An Evidence-Based Cue-Selection Guide and Logic Model to Improve Pressure Ulcer Prevention in Long-term Care.

Pressure ulcers have consistently resisted prevention efforts in long-term care facilities nationwide. Recent research has described cueing innovations that-when selected according to the assumptions and resources of particular facilities-support best practices of pressure ulcer prevention. This article synthesizes that research into a unified, dynamic logic model to facilitate effective staff implementation of a pressure ulcer prevention program.

Implementation of a Recovery-Oriented Training Program for Psychiatric Nurses in the Inpatient Setting: A Mixed-Methods Hospital Quality Improvement Study.

This mixed-methods hospital quality improvement (QI) study primarily aimed to reduce the use of mechanical restraints in a short-stay inpatient psychiatric setting by facilitating change in care delivery through recovery-oriented nursing practice. The implementation of an evidence-based education for psychiatric-mental health registered nurses (PMH-RNs) intended to improve their knowledge of, and attitudes toward, recovery-focused mental health treatment principles. Findings suggest that recovery-oriented training programs for PMH-RNs can be a potentially useful hospital strategy for restraint reduction. In this article, the authors report their findings using the SQUIRE 2.0 framework for publication of QI studies (Ogrinc et al., 2015).