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.

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.

Nursing Assessment of Pressure Injury Risk with the Braden Scale Validated against Sensor-Based Measurement of Movement.

Nursing staff assessment to accurately identify pressure injury (PrI) risk is a hallmark in PrI prevention care. Risk scores from the Braden Scale for Predicting Pressure Sore Risk© (hereafter Braden), a commonly used tool for assessing PrI risk, signal the need for preventative care. Braden Mobility, Activity, and Sensory Perception subscale subgroups associated with repositioning movement features help identify preventative strategies that minimize pressure intensity and duration. Evidence confirming subscale rating accuracy is needed. This study compared assessment score accuracy with movement data collected via accelerometer sensor. Sample included 913 nursing home residents from the Turn Everyone and Move for Pressure Ulcer Prevention (TEAM-UP) cluster randomized trial. Movements and Braden Mobility and Activity subscale scores were evaluated for significant differences and associations. Mobility subgroups explained a small-medium amount of variance in mean lying and upright movement features (0.002 ≤ R2 ≤ 0.195). Activity subgroups explained a small-medium amount of variance in mean lying, upright, and ambulating movements (0.016 ≤ R2 ≤ 0.248). Significant associations occurred among subscale subgroups and most movements. Nursing assessment ratings using Braden scale's Mobility and Activity subscale scores are accurate indicators of actual repositioning movements and can be relied upon for PrI prevention care planning for older adults.

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.

Pressure Injury Risk Assessment and Prevention in Patients With COVID-19 in the Intensive Care Unit.

BACKGROUND: Patients critically ill with COVID-19 are at risk for hospital-acquired pressure injury, including device-related pressure injury. METHODS: Braden Scale predictive validity was compared between patients with and without COVID-19, and a logistic regression model was developed to identify risk factors for device-related pressure injury. RESULTS: A total of 1920 patients were included in the study sample, including 407 with COVID-19. Among the latter group, at least 1 hospital-acquired pressure injury developed in each of 120 patients (29%); of those, device-related pressure injury developed in 55 patients (46%). The Braden Scale score area under the receiver operating characteristic curve was 0.72 in patients without COVID-19 and 0.71 in patients with COVID-19, indicating fair to poor discrimination. CONCLUSIONS: Fragile skin and prone positioning during mechanical ventilatory support were risk factors for device-related pressure injury. Clinicians may consider incorporating factors not included in the Braden Scale (eg, oxygenation and perfusion) in routine risk assessment and should maintain vigilance in their efforts to protect patients with COVID-19 from device-related pressure injury.

Improving Pressure Injury Prevention by Using Wearable Sensors to Cue Critical Care Patient Repositioning.

BACKGROUND: Repositioning patients at regular intervals is the standard of care for pressure injury prevention, yet compliance with routine repositioning schedules can be hard to achieve in busy critical care environments. Cueing technology may help improve repositioning compliance. OBJECTIVE: To determine whether using wearable patient sensors to cue nurses about patients' repositioning needs could improve compliance with an every-2-hour repositioning protocol. METHODS: A sequential pretest-posttest study design was used in a 12-bed medical intensive care unit. The study occurred in 2 phases. In phase 1, eligible patients wore a triaxial accelerometer-based sensor; nurses were blinded to the data. In phase 2, the sensor technology provided staff with visual cues about patients' positions and repositioning needs. The primary measure was repositioning protocol compliance, which was compared between phase 1 and phase 2 with weighted t tests. Unit staff members were surveyed before the start of phase 1 and at the end of phase 2. RESULTS: In phase 1, 25 patients met the inclusion criteria. Phase 2 began 1 day after phase 1 and included 29 patients. In phase 1, repositioning compliance was 55%, and the mean repositioning interval was 3.8 hours. In phase 2, repositioning protocol compliance increased to 89%, and the mean repositioning interval was 2.3 hours. Nursing staff survey results showed improved teamwork in phase 2. CONCLUSION: Visual cueing about patients' mobility needs is associated with increased compliance with the facility repositioning protocol.

Increasing Nursing Documentation Efficiency With Wearable Sensors for Pressure Injury Prevention.

BACKGROUND: Documentation presents an overwhelming burden to bedside clinical nurses. Nurses must manually enter several hundred data points into electronic health record flow sheets, taking time from direct patient care and introducing opportunity for documentation errors. LOCAL PROBLEM: A patient record audit revealed a significant gap in documented patient repositioning events. This quality improvement initiative evaluated automated repositioning documentation via a wearable sensor system. METHODS: A pretest-posttest design was used to examine retrospectively collected manual documentation and prospectively collected sensor documentation of patient repositioning events in a 148-bed rural community hospital. Repositioning documentation manually entered into electronic health records during the baseline period (January 1 to February 28, 2018) was compared with automatic, sensor-based repositioning documentation during the implementation period (corresponding months in 2019 and 2020 to eliminate seasonality). RESULTS: A convenience sample of 105 patient records was reviewed. The mean documented patient repositioning interval was 6.6 hours in the baseline period and 2.4 hours in the implementation period. The improvement was most pronounced in patients with obesity, whose mean repositioning interval improved from 9.4 hours to 2.5 hours. Documentation compliance (actual vs expected repositioning documentation) was 31% with manual documentation and 82% with automatic sensor-based documentation. CONCLUSIONS: Repositioning was documented more than 2.5 times as frequently with sensor technology as with manual data entry. Body position and reasons for delayed repositioning events were documented more completely with sensor technology. Automated documentation may improve the accuracy of electronic health records and reduce the documentation burden for nurses.

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.

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.

To Turn or Not to Turn: Exploring Nurses' Decision-Making Processes Concerning Regular Turning of Nursing Home Residents.

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD (n = 62, 70%) and non-ADRD (n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

Real-time Positioning Among Nursing Home Residents Living With Dementia: A Case Study.

Dementia contributes to the development of pressure injuries (PrIs). PURPOSE: This study describes the real-time body positions of 2 nursing home (NH) residents, residing in the United States and living with dementia, to inform development of PrI prevention strategies tailored to individual risk profiles. METHODS: As part of a larger study, eligible residents were fitted with a triaxial accelerometer sensor placed on the anterior chest to monitor body positions 24-hours daily through a 4-week monitoring period. The current study used an observational, prospective design during routine repositioning events for 2 residents. A convenience sample of 2 residents from a single NH wing who were considered moderately at risk for PrI development (Braden Scale score 13-14) with a Brief Interview for Mental Status score in the severely impaired range were selected based on nursing staff recommendation. RESULTS: Sensor data showed that both residents, although "chairfast" according to the Braden Scale, spent <5% in an upright position and the great majority of time reclining at an angle <50%. One (1) resident demonstrated a persistent side preference. CONCLUSIONS: Wearable sensors are not a long-term solution for protecting those with dementia from PrI formation but do provide a crude picture of overall body positions throughout the 24-hour day that may inform individualized PrI prevention strategies. Studies including large samples of NH residents living with dementia are warranted.

Mitigating the Effects of a Pandemic: Facilitating Improved Nursing Home Care Delivery Through Technology.

The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

Insight Into the Movement Behaviors of Nursing Home Residents Living With Obesity: A Report of Two Cases.

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals. PURPOSE: This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk. METHODS: Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly. RESULTS: Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff. CONCLUSION: Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

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.

Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents.

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Evaluation of the Nursing Culture Assessment Tool for Pressure Injury Prevention: A Mixed-methods Study.

The nursing culture in long-term care (LTC) settings may affect quality measures such as pressure injury (PrI) rates. PURPOSE: The study was conducted to evaluate the relevance of an LTC facility's nursing culture to both their quality measures and their staff's perceptions of care in the context of PrI prevention. METHODS: Directors of Nursing (DONs) in 4 purposively selected Medicare/Medicaid-certified skilled nursing facilities were invited by phone, agreed to participate in the 5-day project, and completed an initial 7-item, facility-related survey. Their staff completed the Nursing Culture Assessment Tool (NCAT), a pen-and-paper instrument that comprises 19 items regarding 6 principal dimensions of nursing culture (behaviors, expectations, teamwork, communication, satisfaction, and professional commitment) and participated in focus groups to discuss the NCAT and its findings using standardized probes of the perception of survey salience in relation to PrI prevention practices. Staff, including registered nurses, licensed practical nurses, and certified nursing assistants employed either part- or full-time at each facility, were eligible for study participation over a 5-day period. All data collection and analyses were conducted by the authors. Facility-related data were descriptive only. Analyses of variance were used to test differences in standardized NCAT scores by facility, and focus group transcripts were coded and subjected to structured thematic content analysis. RESULTS: One hundred, nine (109) people completed the NCAT, and 47 participated in focus groups. NCAT scores varied significantly by facility (P value range .001-.027). Staff comments about their respective facility's results focused primarily on communication and teamwork and included both agreement or disagreement with the facility's high or low scores in the context of PrI prevention, as well as suggestions for instrument administration. CONCLUSION: Examination of nursing culture using the NCAT can provide new and targeted perspectives on how frontline workers perceive barriers and facilitators to delivery of PrI prevention in LTC. To support the evidence base regarding their values and beliefs, future research on effective workplace change in LTC settings will require nuanced assessment of the meaning and impact of the nursing culture on worker performance.

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 .