Pressure Injury Mitigation in Prolonged Care: A Randomized Noninferiority and Superiority Trial.

INTRODUCTION: Combat casualties are at increased risk for pressure injuries (PIs) during prolonged casualty care. There is limited research on operational PI risk mitigation strategies. The purpose of this study was to (1) compare a prototype mattress (AirSupport) designed for operational conditions versus the foldable Talon litter and Warrior Evacuation Litter Pad (WELP) on PI risk factors and (2) determine whether the Talon + AirSupport pad was noninferior and superior to the Talon + WELP on skin interface pressure. MATERIALS AND METHODS: Healthy adults (N = 85; 20 men and 65 women), aged 18 to 55 years, were stratified based on body fat percentage and randomized into three groups: Talon (n = 15), Talon + AirSupport (n = 35), and Talon + WELP (n = 35). The participants were asked to lie in a supine position for 1 hour. The outcomes included skin interface pressure (body surface areas: Sacrum, buttocks, occiput, and heels), sacral and buttock skin temperature and moisture, and discomfort and pressure. The study was approved by the University of Washington Institutional Review Board. RESULTS: Aim 1: The Talon had significantly higher peak skin interface pressure versus the AirSupport and WELP on the sacrum, buttocks, occiput, and heels. Skin temperature increase over the 1-hour loaded period was significantly lower on Talon versus AirSupport or WELP, reflecting a lower temperature-induced ischemic load. There was no significant difference in skin moisture changes or discomfort between the surfaces. Aim 2: The upper confidence limits for the difference in skin interface pressure (all body surface areas) for AirSupport versus WELP were below 25 mm Hg, establishing noninferiority of the AirSupport to the WELP. AirSupport was also superior to WELP for the peak interface pressure on the sacrum, occiput, and heels but not on the buttocks. Skin temperature changes (sacrum or buttocks) were not significantly different between the AirSupport and WELP. CONCLUSIONS: The Talon litter presents a PI risk because of increased skin interface pressure, and hence, immediate action is warranted. The decreased PI risk associated with the lower skin interface pressures on the AirSupport and WELP was offset by the higher skin temperature, which may add the equivalent of 20 to 30 mm Hg pressure to the ischemic burden. Thus, any pressure redistribution intervention must be evaluated with a consideration for skin interface pressure, temperature, and moisture. Data from this study were applied to a predictive model for skin damage. Under operational conditions where resources and the environment may limit patient repositioning, it would be expected that casualties would suffer skin damage within 2 to 5 hours, with the occiput as the highest risk area. The severity of predicted skin damage is lowest on the AirSupport, which is consistent with the noninferiority and superiority of the AirSupport mattress compared to the WELP and Talon. Operational utility: The AirSupport and WELP, which were both superior to the Talon, are operationally feasible solutions to mitigate PI risk. The smaller size of the Talon (2.7 kgs compressible) versus the WELP (5 kgs noncompressible) may make them appropriate for different levels of the operational setting.

Acute and intensive care nurses' perspectives on suicide prevention with medically hospitalized patients: Exploring barriers, facilitators, interests, and training opportunities.

AIMS: To explore opportunities for acute and intensive care nurses to engage in suicide prevention activities with patients hospitalized for medical, surgical or traumatic injury reasons. DESIGN: A qualitative descriptive study. METHODS: We conducted two studies consisting of 1-h focus groups with nurses. Study 1 occurred prior to the onset of the COVID-19 pandemic during January and February of 2020 and identified barriers and facilitators of engaging in an eLearning training in suicide safety planning and engaging patients on their units in suicide safety planning. Study 2 occurred in December of 2020 and explored nurses' perspectives on their role in suicide prevention with patients on their units and training needs related to this. The research took place at an urban level 1 trauma center and safety net hospital where nurses universally screen all admitted patients for suicide risk. We conducted a rapid analysis of the focus group transcripts using a top-down, framework-driven approach to identify barriers, facilitators, strategies around barriers, and training interests mentioned. RESULTS: Twenty-seven registered nurses participated. Nurses indicated they serve a population in need of suicide prevention and that the nursing role is an important part of suicide care. A primary barrier was having adequate uninterrupted time for suicide prevention activities and training; however, nurses identified various strategies around barriers and offered suggestions to make training successful. CONCLUSION: Findings suggest training in suicide prevention is important for nurses in this context and there are opportunities for nurses to engage patients in interventions beyond initial screening; however, implementation will require tailoring interventions and training to accommodate nurses' workload in the hospital context. IMPACT: Acute and intensive care nurses play a key role in the public health approach to suicide prevention. Understanding perspectives of bedside nurses is critical for guiding development and deployment of effective brief interventions. NO PUBLIC OR PATIENT INVOLVEMENT: This study is focused on eliciting and exploring perspectives of acute and intensive care nurses.

Satisfaction and Barriers of Surgical Safety Checklist Implementation in a Nonmandatory Adoption Resource-Limited Country.

OBJECTIVES: A surgical safety checklist has been a globally implemented and mandated adoption in several countries. However, its use is not mandatory in Thailand. This study aimed to evaluate the perceptions of surgical personnel on surgical complications and safety and to examine the satisfaction and barriers of surgical safety checklist implementation. METHODS: A survey study was performed between November 2013 and February 2015 in 61 Thai hospitals. A questionnaire capturing demographics, perceptions related to surgical complications and safety, and the satisfaction and barriers of surgical safety checklist implementation was distributed to surgical personnel. RESULTS: A total of 2024 surgical personnel were recruited. Nearly all of them reported experience or knowledge of an adverse surgical event (99.6%). Most thought that it could be preventable (98.2%) and quality care improvement could help reduce the occurrence of adverse events (97.7%). Overall, respondents reported a high level of satisfaction with the checklist (mean [SD] = 3.79 [0.71]). The three areas of highest satisfaction were benefit to the patient (mean [SD] = 4.11 [0.69]), benefit to the organization (mean [SD] = 4.05 [0.68]), and reduction in adverse events (mean [SD] = 4.02 [0.69]). Overall, the barrier for implementation of the checklist was rated as moderate (mean [SD] = 2.52 [0.99]). However, the means of barriers in each period, sign in, time out, and sign out, were rated as low (means [SD] = 2.41 [1.07], 2.50 [1.03], and 2.34 [1.01], respectively). CONCLUSIONS: The data document that the satisfaction with the checklist are fairly high. However, some barriers were identified. Efforts to increase understanding through more rigorous policy enforcement and strategic support may lead to improving the checklist implementation.

Predicting Pressure Injury in Critical Care Patients: A Machine-Learning Model.

BACKGROUND: Hospital-acquired pressure injuries are a serious problem among critical care patients. Some can be prevented by using measures such as specialty beds, which are not feasible for every patient because of costs. However, decisions about which patient would benefit most from a specialty bed are difficult because results of existing tools to determine risk for pressure injury indicate that most critical care patients are at high risk. OBJECTIVE: To develop a model for predicting development of pressure injuries among surgical critical care patients. METHODS: Data from electronic health records were divided into training (67%) and testing (33%) data sets, and a model was developed by using a random forest algorithm via the R package "randomforest." RESULTS: Among a sample of 6376 patients, hospital-acquired pressure injuries of stage 1 or greater (outcome variable 1) developed in 516 patients (8.1%) and injuries of stage 2 or greater (outcome variable 2) developed in 257 (4.0%). Random forest models were developed to predict stage 1 and greater and stage 2 and greater injuries by using the testing set to evaluate classifier performance. The area under the receiver operating characteristic curve for both models was 0.79. CONCLUSION: This machine-learning approach differs from other available models because it does not require clinicians to input information into a tool (eg, the Braden Scale). Rather, it uses information readily available in electronic health records. Next steps include testing in an independent sample and then calibration to optimize specificity.

Noninvasive Blood Pressure Monitoring and Prediction of Fluid Responsiveness to Passive Leg Raising.

BACKGROUND: Intravenous fluid boluses are administered to patients in shock to improve tissue hypoperfusion. However, fluid boluses result in clinically significant stroke volume increases in only about 50% of patients. Hemodynamic responses to passive leg raising measured with invasive and minimally invasive methods are accurate predictors of fluid responsiveness. However, few studies have used noninvasive blood pressure measurement to evaluate responses to passive leg raising. OBJECTIVE: To determine if passive leg raising-induced increases in pulse pressure or systolic blood pressure can be used to predict clinically significant increases in stroke volume index in healthy volunteers. METHODS: In a repeated-measures study, hemodynamic measurements were obtained in 30 healthy volunteers before, during, and after passive leg raising. Each participant underwent the procedure twice. RESULTS: In the first test, 20 participants (69%) were responders (stroke volume index increased by ≥ 15%); 9 (31%) were nonresponders. In the second test, 15 participants (50%) were responders and 15 (50%) were nonresponders. A passive leg raising-induced increase in pulse pressure of 9% or more predicted a 15% increase in stroke volume index (sensitivity, 50%; specificity, 44%). There was no association between passive leg raising-induced changes in systolic blood pressure and fluid responsiveness. CONCLUSION: A passive leg raising-induced change in stroke volume index measured by bioreactance differentiated fluid responders and nonresponders. Pulse pressure and systolic blood pressure measured by oscillometric noninvasive blood pressure monitoring were not sensitive or specific predictors of fluid responsiveness in healthy volunteers.

Reducing the Risk for Pressure Injury During Combat Evacuation.

BACKGROUND: Combat casualties undergoing aeromedical evacuation are at increased risk for pressure injuries. The risk factors pressure and shear are potentially modifiable via solutions appropriate for en route care. OBJECTIVES: To compare transcutaneous oxygen levels and skin temperatures in healthy participants under offloaded (side lying) and loaded (supine or supine with 30° backrest elevation) under 4 conditions: control (no intervention), Mepilex sacral and heel dressings, LiquiCell pad, and Mepilex plus LiquiCell. METHODS: Participants were randomly assigned to 4 groups according to ideal body weight. Backrest positions were randomized. Transcutaneous oxygen level and temperature were measured on the sacrum and the heel; skin interface pressure was measured with an XSensor pressure imaging system. Measurements were obtained for 5 minutes at baseline (offloaded), 40 minutes with participants supine, and 15 minutes offloaded. RESULTS: In the 40 healthy participants, interface pressure, transcutaneous oxygen level, and skin temperature did not differ between the 4 groups. Peak interface pressures were approximately 43 mm Hg for the sacrum and 50 mm Hg for the heel. Sacral transcutaneous oxygen level differed significantly between unloaded (mean, 79 mm Hg; SD, 16.5) and loaded (mean, 57 mm Hg; SD, 25.2) conditions (P < .001) in a flat position (mean, 85.2 mm Hg; SD, 13.6) and with 30° backrest elevation (mean, 66.7 mm Hg; SD, 24.2) conditions (P < .001). Results for the heels and the sacrum were similar. Sacral skin temperature increased significantly across time (approximately 1.0°C). CONCLUSIONS: The intervention strategies did not differ in prevention of pressure injuries.

An exploration of surgical team perceptions toward implementation of surgical safety checklists in a non-native English-speaking country.

BACKGROUND: In-depth information on the success and failure of implementing the World Health Organization surgical safety checklist (SSC) has been questioned in non-native English-speaking countries. This study explored the experiences of SSC implementation and documented barriers and strategies to improve SSC implementation. METHODS: A qualitative study was performed in 33 Thai hospitals. The information from focus group discussions with 39 nurses and face-to-face, in-depth interviews with 50 surgical personnel was analyzed using content analysis. RESULTS: Major barriers were an unclear policy, inadequate personnel, refusals and resistance from the surgical team, English/electronic SSC, and foreign patients. The key strategies to improve SSC implementation were found to be policy management, training using role-play and station-based deconstruction, adapting SSC implementation suitable for the hospital's context, building self-awareness, and patient involvement. CONCLUSION: The barriers of SSC were related to infrastructure and patients. Effective policy management, teamwork and individual improvement, and patient involvement may be the keys to successful SSC implementation.

Patterns of Hand Grip Strength and Detection of Strength Loss in Patients Undergoing Bone Marrow Transplantation: A Feasibility Study.

PURPOSE/OBJECTIVES: To determine the feasibility of measuring hand grip strength (HGS) daily in a population of recipients of bone marrow transplantation (BMT), to describe changes in strength measured by HGS, and to describe relationships between laboratory values (hematocrit, hemoglobin, and absolute neutrophil count) and HGS.
. DESIGN: Prospective, longitudinal, repeated measures, within subject.
. SETTING: Inpatient units at the University of Washington Medical Center in Seattle.
. SAMPLE: 33 patients admitted in preparation for BMT or for complications from BMT.
. METHODS: HGS measured on admission and daily.
. MAIN RESEARCH VARIABLES: HGS, absolute neutrophil count, hemoglobin, and hematocrit.
. FINDINGS: Participants found HGS testing to be relatively easy. Average time to complete testing was 7.2 minutes (SD = 1.95). Nineteen experienced 20% or greater decline in HGS during hospitalization, with nine experiencing decline during the conditioning phase. Age, gender, and hemoglobin correlated with HGS. Strength loss was more likely in those undergoing allogeneic compared to autologous BMT.
. CONCLUSIONS: A majority of patients experienced strength decline during BMT, with a subgroup declining during conditioning. A positive relationship existed between HGS and hemoglobin and hematocrit in participants admitted for conditioning for BMT.
. IMPLICATIONS FOR NURSING: Weakness increases risk for falls. Patients may experience as much as 50% strength loss during the course of hospitalization for BMT. Strength loss occurs in the conditioning phase for some patients.

Midrange Braden Subscale Scores Are Associated With Increased Risk for Pressure Injury Development Among Critical Care Patients.

PURPOSE: The purpose of the current study was to examine the relationship between pressure injury development and the Braden Scale for Pressure Sore Risk subscale scores in a surgical intensive care unit (ICU) population and to ascertain whether the risk represented by the subscale scores is different between older and younger patients. DESIGN: Retrospective review of electronic medical records. SUBJECTS AND SETTING: The sample comprised patients admitted to the ICU at an academic medical center in the Western United States (Utah) and Level 1 trauma center between January 1, 2008 and May 1, 2013. Analysis is based on data from 6377 patients. METHODS: Retrospective chart review was used to determine Braden Scale total and subscale scores, age, and incidence of pressure injury development. We used survival analysis to determine the hazards of developing a pressure injury associated with each subscale of the Braden Scale, with the lowest-risk category as a reference. In addition, we used time-dependent Cox regression with natural cubic splines to model the interaction between age and Braden Scale scores and subscale scores in pressure injury risk. RESULTS: Of the 6377 ICU patients, 214 (4%) developed a pressure injury (stages 2-4, deep tissue injury, or unstageable) and 516 (8%) developed a hospital-acquired pressure injury of any stage. With the exception of the friction and shear subscales, regardless of age, individuals with scores in the intermediate-risk levels had the highest likelihood of developing pressure injury. CONCLUSION: The relationship between age, Braden Scale subscale scores, and pressure injury development varied among subscales. Maximal preventive efforts should be extended to include individuals with intermediate Braden Scale subscale scores, and age should be considered along with the subscale scores as a factor in care planning.

Effectiveness of Probiotic, Prebiotic, and Synbiotic Therapies in Reducing Postoperative Complications: A Systematic Review and Network Meta-analysis.

BACKGROUND: Microbiome-directed therapies are increasingly used preoperatively and postoperatively to improve postoperative outcomes. Recently, the effectiveness of probiotics, prebiotics, and synbiotics in reducing postoperative complications (POCs) has been questioned. This systematic review aimed to examine and rank the effectiveness of these therapies on POCs in adult surgical patients. METHODS: We searched for articles from PubMed, Embase, Cochrane, Web of Science, Scopus, and CINAHL plus. From 2002 to 2015, 31 articles meeting the inclusion criteria were identified in the literature. Risk of bias and heterogeneity were assessed. Network meta-analyses (NMA) were performed using random-effects modeling to obtain estimates for study outcomes. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated. We then ranked the comparative effects of all regimens with the surface under the cumulative ranking (SUCRA) probabilities. RESULTS: A total of 2,952 patients were included. We found that synbiotic therapy was the best regimen in reducing surgical site infection (SSI) (RR = 0.28; 95% CI, 0.12-0.64) in adult surgical patients. Synbiotic therapy was also the best intervention to reduce pneumonia (RR = 0.28; 95% CI, 0.09-0.90), sepsis (RR = 0.09; 95% CI, 0.01-0.94), hospital stay (mean = 9.66 days, 95% CI, 7.60-11.72), and duration of antibiotic administration (mean = 5.61 days, 95% CI, 3.19-8.02). No regimen significantly reduced mortality. CONCLUSIONS: This network meta-analysis suggests that synbiotic therapy is the first rank to reduce SSI, pneumonia, sepsis, hospital stay, and antibiotic use. Surgeons should consider the use of synbiotics as an adjunctive therapy to prevent POCs among adult surgical patients. Increasing use of synbiotics may help to reduce the use of antibiotics and multidrug resistance.

Passive Leg-Raising and Prediction of Fluid Responsiveness: Systematic Review.

Fluid boluses are often administered with the aim of improving tissue hypoperfusion in shock. However, only approximately 50% of patients respond to fluid administration with a clinically significant increase in stroke volume. Fluid overload can exacerbate pulmonary edema, precipitate respiratory failure, and prolong mechanical ventilation. Therefore, it is important to predict which hemodynamically unstable patients will increase their stroke volume in response to fluid administration, thereby avoiding deleterious effects. Passive leg-raising (lowering the head and upper torso from a 45° angle to lying supine [flat] while simultaneously raising the legs to a 45° angle) is a transient, reversible autotransfusion that simulates a fluid bolus and is performed to predict a response to fluid administration. The article reviews the accuracy, physiological effects, and factors affecting the response to passive-leg raising to predict fluid responsiveness in critically ill patients.

Feasibility of Combining Common Data Elements Across Studies to Test a Hypothesis.

PURPOSE: The purpose of this article is to describe the outcomes of a collaborative initiative to share data across five schools of nursing in order to evaluate the feasibility of collecting common data elements (CDEs) and developing a common data repository to test hypotheses of interest to nursing scientists. This initiative extended work already completed by the National Institute of Nursing Research CDE Working Group that successfully identified CDEs related to symptoms and self-management, with the goal of supporting more complex, reproducible, and patient-focused research. DESIGN: Two exemplars describing the group's efforts are presented. The first highlights a pilot study wherein data sets from various studies by the represented schools were collected retrospectively, and merging of the CDEs was attempted. The second exemplar describes the methods and results of an initiative at one school that utilized a prospective design for the collection and merging of CDEs. METHODS: Methods for identifying a common symptom to be studied across schools and for collecting the data dictionaries for the related data elements are presented for the first exemplar. The processes for defining and comparing the concepts and acceptable values, and for evaluating the potential to combine and compare the data elements are also described. Presented next are the steps undertaken in the second exemplar to prospectively identify CDEs and establish the data dictionaries. Methods for common measurement and analysis strategies are included. FINDINGS: Findings from the first exemplar indicated that without plans in place a priori to ensure the ability to combine and compare data from disparate sources, doing so retrospectively may not be possible, and as a result hypothesis testing across studies may be prohibited. Findings from the second exemplar, however, indicated that a plan developed prospectively to combine and compare data sets is feasible and conducive to merged hypothesis testing. CONCLUSIONS: Although challenges exist in combining CDEs across studies into a common data repository, a prospective, well-designed protocol for identifying, coding, and comparing CDEs is feasible and supports the development of a common data repository and the testing of important hypotheses to advance nursing science. CLINICAL RELEVANCE: Incorporating CDEs across studies will increase sample size and improve data validity, reliability, transparency, and reproducibility, all of which will increase the scientific rigor of the study and the likelihood of impacting clinical practice and patient care.

Failure to Redose Antibiotic Prophylaxis in Long Surgery Increases Risk of Surgical Site Infection.

BACKGROUND: Antibiotic prophylaxis is a key component of the prevention of surgical site infection (SSI). Failure to manage antibiotic prophylaxis effectively may increase the risk of SSI. This study aimed to examine the effects of antibiotic prophylaxis on SSI risk. METHODS: A retrospective cohort study was conducted among patients having general surgery between May 2012 and June 2015 at the University of Washington Medical Center. Peri-operative data extracted from hospital databases included patient and operation characteristics, intra-operative medication and fluid administration, and survival outcome. The effects of antibiotic prophylaxis and potential factors on SSI risk were estimated using multiple logistic regression and were expressed as risk ratios (RRs). RESULTS: A total of 4,078 patients were eligible for analysis. Of these, 180 had an SSI. Mortality rates within and after 30 days were 0.8% and 0.3%, respectively. Improper antibiotic redosing increased the risk of SSI (RR 4.61; 95% confidence interval [CI] 1.33-15.91). Other risk factors were in-patient status (RR 4.05; 95% CI 1.69-9.66), smoking (RR 1.63; 95% CI 1.03-2.55), emergency surgery (RR 1.97; 95% CI 1.26-3.08), colectomy (RR 3.31; 95% CI 1.19-9.23), pancreatectomy (RR 4.52; 95% CI 1.53-13.39), proctectomy (RR 5.02; 95% CI 1.72-14.67), small bowel surgery (RR 6.16; 95% CI 2.13-17.79), intra-operative blood transfusion >500 mL (RR 2.76; 95% CI 1.45-5.26), and multiple procedures (RR 1.40; 95% CI 1.01-1.95). CONCLUSIONS: These data demonstrate that failure to redose prophylactic antibiotic during long operations increases the risk of SSI. Strengthening a collaborative surgical quality improvement program may help to eradicate this risk.

Full-Thickness and Unstageable Pressure Injuries That Develop in Nursing Home Residents Despite Consistently Good Quality Care.

PURPOSE: The purpose of this study was to determine whether stage 3, 4, and unstageable pressure injuries develop despite consistently good quality care (CGQC); ascertain whether these wounds occur without prior recognition of a lower-stage pressure injury; and to describe and analyze characteristics of nursing home residents and their higher-stage pressure injuries. DESIGN: Descriptive, nonexperimental, prospective analysis. SUBJECTS AND SETTING: A convenience sample of 20 residents from facilities participated in the study; research sites were located in 7 counties in Western Washington and Orange County, along with a single site in Wisconsin. METHODS: CGQC facilities were identified using a 3-step incremental approach. Research assistants verified CGQC at the facility level. After data collection was complete, a Longitudinal, Expert, All-Data Panel reviewed cases for a final resident-level validity check for CGQC. Remaining cases were submitted to analysis. RESULTS: Residents who developed advanced stage pressure injuries despite CGQC were older, had limited mobility, dementia, comorbid conditions, urinary or fecal incontinence, and infections. The pressure injuries were relatively small and had little-to-no undermining, exudate, or edema. CONCLUSIONS: Stage 3, 4, and unstageable pressure injuries were observed in nursing home residents despite CGQC. Results from this study may serve as a baseline for further research to evaluate characteristics of these wounds when they develop under settings of poor-quality care. Findings also may be useful in creating evidence-based practice guidelines to support decision making around mandatory reporting, diagnosis, and prosecution.

Practices and impacts post-exposure to blood and body fluid in operating room nurses: A cross-sectional study.

BACKGROUND: Improper or inadequate actions taken after blood and body fluid exposures place individuals at risk for infection with bloodborne pathogens. This has potential, significant impact for health and well-being. OBJECTIVES: To evaluate the practices and the personal impact experienced following blood and body fluid exposures among operating room nurses. DESIGN: A cross-sectional, multi-center study. SETTINGS: Government and private hospitals from all parts of Thailand. PARTICIPANTS: Operating room nurses from 247 hospitals. METHODS: A questionnaire eliciting responses on characteristics, post-exposure practices, and impacts was sent to 2500 operating room nurses. RESULTS: Usable questionnaires were returned by 2031 operating room nurses (81.2%). Of these 1270 had experience with blood and body fluid exposures (62.5%). Most operating room nurses did not report blood and body fluid exposures (60.9%). The major reasons of underreporting were low risk source (40.2%) and belief that they were not important to report (16.3%). Improper post-exposure practices were identified, 9.8% did not clean exposure area immediately, 18.0% squeezed out the wound, and 71.1% used antiseptic solution for cleansing a puncture wound. Post-exposure, 58.5% of them sought counseling, 16.3% took antiretroviral prophylaxis, 23.8% had serologic testing for hepatitis B and 43.1% for hepatitis C. The main personal impacts were anxiety (57.7%), stress (24.2%), and insomnia (10.2%). CONCLUSIONS: High underreporting, inappropriate post-exposure practices and impacts of exposure were identified from this study. Comprehensive education and effective training of post-exposure management may be keys to resolving these important problems.

Prevalence and risk factors of needlestick injuries, sharps injuries, and blood and body fluid exposures among operating room nurses in Thailand.

BACKGROUND: Operating room nurses are at high risk for occupational exposure to bloodborne pathogens. This study examined the prevalence of and risk factors for needlestick injuries (NSIs), sharps injuries (SIs), and blood and body fluid exposures (BBFEs) among operating room nurses in Thai hospitals. METHODS: A cross-sectional study was performed in 247 Thai hospitals. Questionnaires eliciting demographic data and information on injury occurrence and risk factors were distributed to 2500 operating room nurses, and 2031 usable questionnaires were returned, for a response rate of 81.2%. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multiple logistic regression analysis. RESULTS: The prevalence of NSIs, SIs, and BBFEs was 23.7%, 9.8%, and 40.0%, respectively. Risk factors for NSIs were training without practice (OR, 1.67; 95% CI, 1.29-2.17), haste (OR, 4.81; 95% CI, 3.41-6.79), lack of awareness (OR, 1.36; 95% CI, 1.04-1.77), inadequate staffing (OR, 1.60; 95% CI, 1.21-2.11), and outdated guidelines (OR, 1.69; 95% CI, 1.04-2.74). One risk factor was identified for SIs: haste (OR, 2.43; 95% CI, 1.57-3.76). Risk factors for BBFEs were long working hours per week (OR, 2.07; 95% CI, 1.06-4.04), training without practice (OR, 1.55; 95% CI, 1.25-1.91), haste (OR, 1.66; 95% CI, 1.30-2.13), lack of awareness (OR, 1.54; 95% CI, 1.22-1.95), not wearing protective equipment (OR, 1.61; 95% CI, 1.26-2.06), and inadequate staffing (OR, 1.63; 95% CI, 1.26-2.11). CONCLUSION: This study highlights the high prevalence of NSIs, SIs, and BBFEs among Thai operating room nurses. Preventable risk factors were identified. Appropriate guidelines, adequate staffing, proper training, and self-awareness may reduce these occurrences.

Defining Unstageable Pressure Ulcers as Full-Thickness Wounds: Are These Wounds Being Misclassified?

PURPOSE: The purpose of this study was to describe the evolution of unstageable pressure ulcers (PUs) over time to determine if their healing trajectory is consistent with full- or partial-thickness wounds. DESIGN: Retrospective review of electronic medical record and a clinical PU database. SUBJECTS AND SETTINGS: Patients with hospital-acquired, unstageable PUs were evaluated. Subjects were cared for at a level 1 trauma/burn center and safety net hospital in the Pacific Northwest between November 2007 and March 2011. METHODS: Electronic medical records and a clinical PU database for 194 unstageable PUs were examined. The PU database is managed by certified wound care nurses; it includes data on all verified hospital-acquired PUs since 2007. The unit of analysis for this study was the individual PU site. RESULTS: Of the initial 194 unstageable PUs identified, 120 were excluded due to lack of data needed to address research questions. Out of the 74 unstageable PUs that remained in the study, approximately one-third (33.8%) were found to follow a healing trajectory consistent with partial-thickness wounds. CONCLUSION: Findings indicate that while approximately two-thirds of unstageable PUs demonstrate healing trajectories consistent with full-thickness wounds, slightly more than a third follow a trajectory consistent with partial-thickness wounds. Additional research is needed to clarify the healing trajectories of unstageable PUs and to determine whether the current definition for unstageable PUs is adequate.

The Effects of Local Warming on Surgical Site Infection.

BACKGROUND: Surgical site infections (SSI) account for a major proportion of hospital-acquired infections. They are associated with longer hospital stay, readmissions, increased costs, mortality, and morbidity. Reducing SSI is a goal of the Surgical Care Improvement Project and identifying interventions that reduce SSI effectively is of interest. In a single-blinded randomized controlled trial (RCT) we evaluated the effect of localized warming applied to surgical incisions on SSI development and selected cellular (immune, endothelial) and tissue responses (oxygenation, collagen). METHODS: After Institutional Review Board approval and consent, patients having open bariatric, colon, or gynecologic-oncologic related operations were enrolled and randomly assigned to local incision warming (6 post-operative treatments) or non-warming. A prototype surgical bandage was used for all patients. The study protocol included intra-operative warming to maintain core temperature ≥36°C and administration of 0.80 FIO2. Patients were followed for 6 wks for the primary outcome of SSI determined by U.S. Centers for Disease Control (CDC) criteria and ASEPSIS scores (additional treatment; presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues; isolation of bacteria; and duration of inpatient stay). Tissue oxygen (PscO2) and samples for cellular analyses were obtained using subcutaneous polytetrafluoroethylene (ePTFE) tubes and oxygen micro-electrodes implanted adjacent to the incision. Cellular and tissue ePTFE samples were evaluated using flow cytometry, immunohistochemistry, and Sircol™ collagen assay (Biocolor Ltd., Carrickfergus, United Kingdom). RESULTS: One hundred forty-six patients participated (n=73 per group). Study groups were similar on demographic parameters and for intra-operative management factors. The CDC defined rate of SSI was 18%; occurrence of SSI between groups did not differ (p=0.27). At 2 wks, warmed patients had better ASEPSIS scores (p=0.04) but this difference was not observed at 6 wks. There were no significant differences in immune, endothelial cell, or collagen responses between groups. On post-operative days one to two, warmed patients had greater PscO2 change scores with an average PscO2 increase of 9-10 mm Hg above baseline (p<0.04). CONCLUSIONS: Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and FIO2 level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. PscO2 increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions.

Changes in classifications of chronic lower-limb wound codes in patients with diabetes: ICD-9-CM versus ICD-10-CM.

PURPOSE: To enhance the learner's competence with knowledge of changes in classifications of chronic lower limb wound codes from ICD-9-CM to ICD-10-CM in patients with diabetes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Identify the upcoming transition date and coding differences of ICD-9-CM and ICD-10-CM coding.2. Interpret the author's study population, methods, and design.3. Summarize the author's study findings comparing ICD-9-CM coding to ICD-10-CM coding. OBJECTIVE: To determine the sensitivity and specificity of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for individuals with diabetes and foot ulcers. DESIGN AND METHODS: Wound care providers and researchers are concerned about the potential impacts when the United States transitions from ICD-9-CM to ICD-10-CM. To identify the impact on diabetic foot ulcers, health history and wound variables were prospectively assessed with criterion-standard data from a prospective study of 49 patients with 65 foot ulcer episodes representing 81 incident foot ulcers. The ICD-9-CM and ICD-10-CM code sets were mapped to correctly classify individuals with diabetes and foot ulcers. RESULTS: Frequencies for health history variables were similar in both systems. The ICD-9 code did not capture any data on laterality (left or right) or ulcer depth/severity. The ICD-9 captured 69 of 81 incident ulcers (85%) and 94% of heel and midfoot ulcers, whereas the ICD-10 code captured 78 of 81 incident ulcers (96%) and all incident heel or midfoot ulcers. Sensitivity and specificity for ulcer characteristics were consistently lower in ICD-9 than in ICD-10. CONCLUSIONS: The ICD-9 and ICD-10 are similar for data capture on health history variables, but wound variables are captured more accurately using ICD-10. The increased specificity of ICD-10 for ulcer location and severity improves identification and tracking ulcers during an episode of care.