Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study.

AIM: To assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement. DESIGN: Interrater agreement study. METHODS: Data were collected from November 2019 to December 2022. Paired nurse-assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence-adjusted and bias-adjusted kappa. RESULTS: Ninety-four nurse assessors participated. Absolute agreement of not-at-risk versus at-risk-any-level was substantial, but absolute agreement of risk-level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower-risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher-risk patients. CONCLUSION: There were clear differences in pressure injury risk-level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation. IMPACT: The results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool. REPORTING METHOD: This study adhered to the GRRAS reporting guideline. PATIENT/PUBLIC CONTRIBUTION: No patient or public involvement in this study. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Educators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.

Use of a risk-based intervention bundle to prescribe and implement interventions to prevent pressure injury: An observational study.

AIM: To explore the relationship between the prescription and implementation of pressure injury preventative interventions following risk assessment combined with a risk-stratified intervention bundle. DESIGN: Single-centre, cross-sectional, observational, prospective. METHODS: The charts and bedsides of 341 adult inpatients were examined. Data collection included pressure injury risk level, prescribed preventative interventions and evidence of intervention implementation. RESULTS: Most patients (68.6%) were at risk of pressure injury, and most interventions were prescribed according to their risk level. However, evidence from direct observation and/or documentation indicated intervention implementation rates were relatively poor. Of nine interventions mandated for all patients, compliance with three patient-/carer-focused interventions was particularly poor, with evidence indicating they had been implemented for 3%-10% of patients. Also, nutritional screening-related interventions were implemented poorly. Clinically indicated implementation of heel-elevation devices and bariatric equipment was low for at-risk patients, and the implementation of interventions for patients with existing pressure injuries was suboptimal. Significant proportions of several interventions that were observed as having been implemented were not documented as such. CONCLUSION: While most interventions were prescribed according to patient risk level, the overall implementation of interventions was poor. However, the results may in part be due to failure to document interventions as opposed to omitting them. IMPLICATIONS FOR PATIENT CARE: Documentation of interventions is crucial as it provides evidence of the care provided. An increased focus on documentation of pressure injury preventative interventions is required, with a clear distinction between prescription and implementation. IMPACT: The results highlighted several deficiencies in care, particularly relating to evidence of implementation, patient involvement and nutritional screening. The results from this study will be used to inform and improve future pressure injury prevention practice within the study hospital and should be used to inform and benchmark pressure injury preventative practices in other hospitals. REPORTING METHOD: The study adheres to STROBE guidelines. PATIENT OR PUBLIC CONTRIBUTION: None.

The Chinese Mandarin COMHON Index and Braden Scale to assess pressure injury risk in intensive care: An inter-rater reliability and convergent validity study.

BACKGROUND: The COMHON Index is an intensive-care-specific pressure injury risk assessment tool, which has demonstrated promising psychometric properties. It has been translated into Chinese Mandarin but requires inter-rater reliability testing and comparison to the standard care instrument (Braden Scale) before clinical use. OBJECTIVES: This study aimed to test and compare the inter-rater reliability and convergent validity of the Chinese Mandarin versions of the COMHON Index and Braden Scale. METHODS: The study was conducted in a Chinese comprehensive intensive care unit. Based on a sample size calculation, five registered nurse raters with at least 6-months experience independently conducted risk assessments for 20 adult patients using both the COMHON Index and Braden Scale. Intraclass correlations (ICC) for inter-rater reliability, standard errors of measurement (SEM), and minimally detectable change (MDC) were calculated. Convergent validity was assessed using Pearson Product Moment Correlation for sum scores and Spearman's rho for subscales. RESULTS: Inter-rater reliability of COMHON Index and Braden Scale sum scores was very high (ICC [1,1] = 0.973; [95% confidence interval 0.949-0.988]; SEM 0.54; MDC 1.50) and high (ICC [1,1] = 0.891; [95% confidence interval 0.793-0.951]; SEM 0.93; MDC 2.57), respectively. All COMHON-Index subscales demonstrated ICC values >0.6, whereas two Braden Scale subscales (Mobility, Activity) were below this threshold. Instrument sum scores were strongly correlated (Pearson's r = -0.76 [r2 = 0.58]; p < 0.001), as were three subscale item pairs (mobility rs= -0.56 [r2 = 0.32]; nutrition rs= -0.63 [r2 = 0.39]; level of consciousness/sensory perception rs= -0.67 [r2 = 0.45] p < 0.001). CONCLUSION: Both the COMHON Index and Braden Scale demonstrated high levels of inter-rater reliability and measured similar constructs. However, the COMHON Index demonstrated superior inter-rater reliability and the results suggest that it better detects changes in patient condition and subsequently pressure injury risk. Further testing is recommended.

Clinicians' perceptions of "enhanced recovery after surgery" (ERAS) protocols to improve patient safety in surgery: a national survey from Australia.

BACKGROUND: Surgical patients are at risk of postoperative complications, which may lead to increased morbidity, mortality, hospital length-of-stay and healthcare costs. Enhanced Recovery After Surgery (ERAS®) protocols are evidence-based and have demonstrated effectiveness in decreasing complications and associated consequences. However, their adoption in Australia has been limited and the reason for this is unclear. This study aimed to describe clinicians' perceptions of ERAS protocols in Australia. METHODS: A national online survey of anaesthetists, surgeons and nurses was undertaken. Invitations to participate were distributed via emails from professional colleges. The 30-item survey captured respondent characteristics, ERAS perceptions, beliefs, education and learning preferences and future planning considerations. The final question was open-ended for elaboration of perceptions of ERAS. Descriptive and inferential statistics were used to describe and compare group differences across disciplines relative to perceptions of ERAS. RESULTS: The sample included 178 responses (116 nurses, 65.2%; 36 surgeons, 20.2%; 26 anaesthetists, 14.6%) across six states and two territories. More than half (n = 104; 58.8%) had used ERAS protocols in patient care, and most perceived they were 'very knowledgeable' (n = 24; 13.6%) or 'knowledgeable' (n = 71; 40.3%) of ERAS. However, fewer nurses had cared for a patient using ERAS (p <.01) and nurses reported lower levels of knowledge (p <.001) than their medical counterparts. Most respondents agreed ERAS protocols improved patient care and financial efficiency and were a reasonable time investment (overall Md 3-5), but nurses generally recorded lower levels of agreement (p.013 to < 0.001). Lack of information was the greatest barrier to ERAS knowledge (n = 97; 62.6%), while seminars/lectures from international and national leaders were the preferred learning method (n = 59; 41.3%). Most supported broad implementation of ERAS (n = 130; 87.8%). CONCLUSION: There is a need to promote ERAS and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints.

Assessment of pressure injury risk in intensive care using the COMHON index: An interrater reliability study.

OBJECTIVES: To assess the interrater reliability of the COMHON (level of COnciousness, Mobility, Haemodynamics, Oxygenation, Nutrition) Index pressure injury risk assessment tool. DESIGN: Interrater reliability was tested. Twenty-five intensive care patients were each assessed by five different nurse-raters from a pool of intensive care nurses who were available on the days of assessment. In total, 25 nurses participated. SETTING: Two general and one cardiovascular surgery intensive care units in Istanbul, Turkey. MAIN OUTCOME MEASURES: Interrater reliability was analysed using intraclass correlations, and standard errors of measurement (SEM) were calculated for sum scores, risk level and item scores. Minimally detectable change (MDC) was also calculated for sum score. Consistency between paired raters was analysed using Pearson's Product Moment Correlation (r) for sum score and Spearman's rho (rs) for ordinal variables. RESULTS: All assessments were completed in ≤5 min. Interrater reliability was very high [ICC (1,1) = 0.998 (95 % CI 0.996 - 0.999)] with a SEM of 0.14 and MDC of 0.39. Consistency between paired raters was strong for sum and item scores and risk levels (coefficients >0.6). All scale items showed correlations of >.3 with the sum score. CONCLUSION: The results demonstrate near-perfect interrater reliability. Further research into the psychometric properties of the COMHON Index and its impact on preventative intervention use is warranted. IMPLICATIONS FOR CLINICAL PRACTICE: Pressure injury risk assessment within intensive care should be setting-specific due to the unique risk factors inherent to the patient population, which are not considered by general pressure injury risk assessment tools. An intensive care-specific pressure injury risk assessment tool was tested and demonstrated high reliability between intensive care nurses. Further research is needed to understand how its use in practice affects preventative intervention implementation and, in turn, how it impacts pressure injury outcomes.

The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta-analysis.

BACKGROUND: Numerous interventions for pressure injury prevention have been developed, including care bundles. OBJECTIVE: To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients. DATA SOURCES: The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023). STUDY ELIGIBILITY CRITERIA: Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded. PARTICIPANTS AND INTERVENTIONS: Bundles with ≥3 components directed towards patients and implemented in ≥2 hospital services were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation. RESULTS: Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42023423058. TWEETABLE ABSTRACT: Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low.