Psychometric properties of the Braden scale to assess pressure injury risk in intensive care: A systematic review.

OBJECTIVE: To analyse the psychometric properties of the Braden scale to assess pressure injury risk in adults in intensive care. DESIGN: A systematic review was conducted, with literature searches undertaken in five electronic databases. No date limits were applied. Selection, data extraction and risk of bias assessment were completed by two reviewers independently. A customised data extraction template was used, with risk of bias conducted using the COSMIN Risk of Bias checklist. Data were analysed using narrative synthesis. RESULTS: Thirty-four studies met inclusion criteria. Two studies reported internal consistency with Cronbach's alpha ranging from poor (0.43) to good (0.85). For interrater reliability, only four studies reported intraclass correlation, ranging from 0.66 to 0.96 for Braden sum score. Three studies reported convergent validity, with strong associations found between the COMHON Index (r = 0.70), Cubbin-Jackson scale (r = 0.80), and Norton scale (r = 0.77), but contrasting associations with the Waterlow score (r = 0.22 to 0.72). A large majority of studies reported predictive validity (n = 29), with wide variability. Several studies investigated optimal cut-off scores, with the majority indicating this was in the range of 12-14. CONCLUSIONS: This review demonstrates inconsistency in the psychometric properties of the Braden scale in ICU settings. Further research is needed to determine suitability of the Braden scale for ICU before it can be recommended as standard for clinical practice, including comparison with other ICU-specific risk assessment tools. IMPLICATIONS FOR CLINICAL PRACTICE: When used in ICU, the reliability, validity and reported cut-off scores of the Braden scale are variable. As a predictive tool, the scale should be used cautiously. In ICU, the value of the Braden scale resides in its ability to identify patients that are most at risk of developing a pressure injury and to implement preventative measures to mitigate identified risk factors.

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.

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.

Healing rate of hospital-acquired skin tears using adhesive silicone foam versus meshed silicone interface dressings: A prospective, randomized, non-inferiority pilot study.

BACKGROUND: A skin tear is a traumatic wound that occurs in up to one in five hospitalized patients. Nursing care includes application of a dressing to create a moist wound healing environment. AIM: To compare the effectiveness of two standard dressings (adhesive silicone foam vs. meshed silicone interface) to heal hospital-acquired skin tear. METHODS: An intention-to-treat pilot study was designed using a randomized, non-inferiority trial in an Australian tertiary hospital setting. Consenting participants (n = 52) had acquired a skin tear within the previous 24 h and had agreed to a 3-week follow-up. Data were collected between 2014 and 2020. The primary outcome measure was wound healing at 21 days. RESULTS: Baseline characteristics were similar in both arms. Per protocol, 86% of skin tears were fully healed at 3 weeks in the adhesive silicone foam group, compared to 59% in the meshed silicone interface group. Greater healing was observed across all skin tear categories in the adhesive silicone foam dressing group. In the intention-to-treat sample, healing was 69% and 42%, respectively. CONCLUSIONS: Results suggest the adhesive silicone foam dressing may be superior, as it produced clinically significant healing of skin tears at 3 weeks compared to the meshed silicone interface dressing. Accounting for potential loss to follow-up, a sample of at least 103 participants per arm would be required to power a definitive study.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study.

BACKGROUND: Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks. OBJECTIVE: To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions. DESIGN: Prospective, interrupted time-series study. SETTINGS: Seven adult inpatient wards in three Australian hospitals. PARTICIPANTS: 825 adults with 867 peripheral intravenous catheters. METHODS: Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections. RESULTS: Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention). CONCLUSIONS: Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter. ANZCTR TRIAL REGISTRATION: ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017. TWEETABLE ABSTRACT: #IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

A short multi-factor screening tool to assess falls-risk in older people presenting to an Australian emergency department: A feasibility study.

OBJECTIVE: The purpose of this study was to evaluate use of a short multi-factor falls-risk screening tool for older people within the emergency department, to enable rapid identification of falls-risk and triggers for multidisciplinary referral for further falls-specific assessment. METHODS: Older people, aged ≥70 years, presenting to the emergency department with a fall-related injury or disease (n = 137) were recruited by a research nurse following randomisation. A short multi-factor screening tool was completed, comprised of 14 falls-risk-related assessment components. RESULTS: Only one participant did not generate any referrals. Participants generated most referrals for medications (85.4%), social and housing (84.6%), vision (67.2%), podiatry (66.9%), or function and mobility (54.7%). Based on our results, the screening tool could be reduced to eleven components. The median time-to-screen was 11 min (IQR 9-15), with 736 triggers generated for referral and further assessment of falls-risk. CONCLUSION: Falls are a major cause of ED presentation for older people. A short multi-factor screening tool with eleven components could be adapted to local familiar falls-risk tools and be completed in less than 10 min. Further research to trial the feasibility of completing ED referrals based on screening results is required to confirm the usefulness of such screening and referral within the ED.

Critical care nursing policy, practice, and research priorities: An international cross-sectional study.

PURPOSE: To examine the status of critical care nursing internationally, assess the impact of the COVID-19 pandemic, and identify research priorities by surveying professional critical care nursing organizations (CCNOs) worldwide. DESIGN: A descriptive survey methodology was used. This study is the sixth worldwide quadrennial review to assess international critical care nursing needs and provide evidence to inform critical care nursing policy, practice and research priorities globally. METHODS: The sixth World Federation of Critical Care Nurses survey of CCNOs was emailed to potential participants from countries with CCNOs or known critical care nurse leaders. Data were collected online using Survey Monkey™. Responses were entered into SPSS version 28 software (IBM Corp.) and analyzed by geographical region and national wealth group. FINDINGS: Ninety-nine national representative respondents participated in the survey (70.7% response rate). The most important issues identified were working conditions, teamwork, staffing levels, formal practice guidelines, wages, and access to quality education programs. The top five CCNO services that were of most importance were providing national conferences, local conferences, workshops and education forums, practice standards and guidelines, and professional representation. Important pandemic-related services and activities provided by CCNOs included addressing emotional and mental well-being of nurses, providing guidance related to nurse staffing/workforce needs, assisting to coordinate efforts to obtain personal protective equipment supplies, serving as a country liaison with the World Health Organization's COVID-19 response activities, and assisting in the development and implementation of policies regarding standards of care. The most important contributions expected from the World Federation of Critical Care Nurses were standards for professional practice, standards for clinical practice, website resources, professional representation, and providing online education and training materials. The top five research priority areas were: stress levels (inclusive of burnout, emotional exhaustion and compassion fatigue); critical care nursing shortage, skill mix and workforce planning; recruitment, retention, turnover, working conditions; critical care nursing education and patient outcomes; and adverse events, staffing levels, patient outcomes. CONCLUSIONS: The results highlight priority areas for critical care nursing internationally. The COVID-19 pandemic impacted critical care nurses as direct care providers. As a result, addressing the ongoing needs of critical care nurses remains a priority area of focus. The results also highlight important policy and research priorities for critical care nursing globally. Results of this survey should be incorporated into strategic action plans at the national and international levels. CLINICAL RELEVANCE: Issues of importance to critical care nurses including research and policy priorities during and following COVID-19 are now clarified through this survey. The impact and importance that COVID-19 has had on critical care nurses and their preferences and priorities are provided. Clear guidance to leaders and policy makers on where critical care nurses would like to see greater focus and attention to help strengthen the contribution of critical care nursing practice to the global healthcare agenda.

State-wide prevalence of pressure injury in intensive care versus acute general patients: A five-year analysis.

AIM: The aim of this study was to analyse prevalence of pressure injury in intensive care versus non-intensive care patients. BACKGROUND: Hospital-acquired pressure injury is an enduring problem. Intensive care patients are more susceptible due to multiple risk factors. Several studies have indicated that intensive care patients are more likely than general patients to develop pressure injuries. DESIGN: Secondary data analysis. METHODS: Eighteen general hospitals with intensive care units were included. The sample included all consenting patients. Logistic regression modelling was used to derive prevalence and effect estimates. STROBE reporting guidelines were followed. RESULTS: The sample comprised 15,678 patients; 611 were in intensive care. The crude prevalence estimate of hospital-acquired pressure injury was 9.6% in intensive care and 2.1% in non-intensive care patients. The ≥Stage II hospital-acquired prevalence estimate in was 8.6% intensive care and 1.2% in non-intensive care patients. Intensive care patients were at markedly increased risk of hospital-acquired pressure injury compared with non-intensive care patients, with risk persisting after adjusting for pressure injury risk score. Risk of ≥ Stage II hospital-acquired pressure injury was further elevated. Intensive care patients had a higher pressure injury risk level and developed a greater proportion of severe hospital-acquired pressure injuries than non-intensive care patients. In intensive care, most hospital-acquired pressure injuries were found on the sacrum/coccyx and heels. CONCLUSIONS: There were significant differences between the hospital-acquired pressure injury prevalence of intensive care versus non-intensive care patients, which is consistent with previous studies. Overall, the prevalence of hospital-acquired pressure injury in intensive care is relatively high, indicating that their prevention should remain a high priority within the intensive care setting. RELEVANCE TO CLINICAL PRACTICE: These results may be used for benchmarking and provide a focus for future education and practice improvement efforts. PATIENT OR PUBLIC CONTRIBUTION: Neither patients nor the public were directly involved in the project.

Reporting accuracy of pressure injury categorisation in an acute tertiary hospital: A four-year analysis.

AIM: To determine the reporting accuracy of pressure injury categorisation by bedside clinicians, compared with nurse experts. BACKGROUND: Pressure injuries are an enduring complication of hospitalisation. The categorisation of pressure injury affects treatment and management decision-making and use of resources, and severe hospital-acquired pressure injury incidence is used to benchmark quality of care. However, it is unclear how accurately pressure injuries are categorised by clinicians in practice. DESIGN: Secondary analysis of hospital pressure injury incident and validation data. METHODS: All pressure injuries reported in adults between 2016 and 2019 that were subsequently validated by nurse experts were analysed. Absolute agreement is reported using percentages, with inter-rater agreement reported using Kappa measure of agreement. The GRRAS reporting guideline was followed. RESULTS: Of 6186 pressure injuries that were analysed, the category was reported correctly in 67.3% (n = 4163), with an overall moderate level of inter-rater agreement by category (Κ = .567, p < .001). Of those found to be non-pressure injuries when validated (18.3%, n = 1129), most were reported originally as stage II (41.2%, n = 465) or stage I (30.5%, n = 344), and 13.4% (n = 151) were categorised initially as unstageable. The majority reported initially as stage I, stage II, suspected deep tissue injury or mucosal pressure injury were validated, whereas half of those reported initially as stage III or IV were validated and less than a third of those reported initially as unstageable pressure injuries were validated. CONCLUSIONS: This study provides important insight into the accuracy of pressure injury categorisation. Whilst moderate agreement of categorisation was found between reporting clinicians and nurse experts, pressure injury differential diagnosis and categorisation of severe injuries were inadequate. RELEVANCE TO CLINICAL PRACTICE: These results may be used for benchmarking and provide a focal point for future education and practice improvement efforts. PATIENT OR PUBLIC CONTRIBUTION: Neither patients nor the public were directly involved in the project.

Patient and carer experience of living with a pressure injury: A meta-synthesis of qualitative studies.

INTRODUCTION: Pressure injuries are a significant cause of harm, contributing to increased mortality and financial burden on the healthcare system. Significant research on pressure injury risk assessment, prevention and treatment exists, but limited research exploring the patient and carer experience of living with pressure injury. AIMS: The aim of this meta-synthesis was to describe the patient and carer experience of living with a pressure injury. DESIGN: Meta-synthesis. METHODS: A prospective review protocol was registered, and systematic search conducted across five electronic databases. The PRISMA 2020 checklist for reporting systematic reviews was used. Two reviewers independently undertook screening and review of articles, using the CASP checklist for evaluating qualitative research. A meta-synthesis using thematic content analysis was undertaken. RESULTS: Twelve studies met the inclusion criteria. Meta-synthesis led to the construction of three primary themes: loss of autonomy and independence, psychological effects, and adjustment. Within these primary themes, sub-themes of dependence, social isolation and social avoidance behaviours, feelings and emotions, loss, managing, physical consequences, service provision, and functional challenges, were identified. CONCLUSION: The psychology and mindset of those involved, and support to navigate the challenges that arise are two unique and clinically relevant categorisations to guide provision of pressure injury care. Adaptation to a pressure injury is multi-faceted and contextual, challenges to adaptation create additional psychological burden. Interventions encompassing all facets of the experience are necessary. Current research into experiences is limited, and further research to support interventions is necessary.

Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review.

BACKGROUND: Whilst performing a pressure injury risk assessment is not in itself preventive, risk status identification is critical to inform the judicious implementation of prevention strategies. Risk assessment is mostly undertaken using a structured tool informed by clinical judgement, though there is a perception that use of clinical judgement alone may be sufficient. OBJECTIVES: Within acute hospital settings, to identify differences in outcomes (risk status, preventive interventions) following nursing assessment of pressure injury risk when using a structured assessment tool compared to clinical judgement. DESIGN: Systematic review. DATA SOURCES: EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus, Web of Science, Ovid EMBASE. METHODS: Primary research relevant to the objectives was eligible for inclusion. Databases were searched in February 2021 (limits: date 2010-2020, English language, adults). Two reviewers undertook the review process, with a third as arbitrator. Appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Included studies are synthesised narratively. Reporting is in accordance with the PRISMA Statement. RESULTS: Five moderate to high-quality studies were included. Synthesis was limited by heterogeneity. Several risk assessment tools and methods of clinical judgement were used. Three studies reported pressure injury risk status using both assessment approaches, but in only one did nurses undertake both. Risk status, as identified by each method, varied and was sometimes contradictory. Three studies reported some elements of preventive intervention prescription and/or implementation following risk assessment, but comparison between approaches was limited. CONCLUSIONS: Some research suggests that risk status varies across different methods of pressure injury risk assessment, but it is unclear what impact this has on preventive intervention use. Risk status was not well linked to preventive interventions. Research is warranted to examine the influence that each approach to risk assessment alone and combined has on identified risk and preventive intervention prescription and implementation. REGISTRATION: A protocol was prospectively registered with PROSPERO (CRD42021224747).

Pressure injury prevention practice in Australian intensive care units: A national cross-sectional survey.

INTRODUCTION: Pressure injury (PI) is an ongoing problem for patients in intensive care units (ICUs). The aim of this study was to explore the nature and extent of PI prevention practices in Australian adult ICUs. MATERIALS AND METHODS: An Australian multicentre, cross-sectional study was conducted via telephone interview using a structured survey instrument comprising six categories: workplace demographics, patient assessment, PI prevention strategies, medical devices, skin hygiene, and other health service strategies. Publicly funded adult ICUs, accredited with the College of Intensive Care Medicine, were surveyed. Data were analysed using descriptive statistics and chi-square tests for independence to explore associations according to geographical location. RESULTS: Of the 75 eligible ICUs, 70 responded (93% response rate). PI was considered problematic in two-thirds (68%) of all ICUs. Common PI prevention strategies included risk assessment and visual skin assessment conducted within at least 6 h of admission (70% and 73%, respectively), a structured repositioning regimen (90%), use of barrier products to protect the skin (94%), sacrum or heel prophylactic multilayered silicone foam dressings (88%), regular PI chart audits (96%), and PI quality improvement projects (90%). PI prevention rounding and safety huddles were used in 37% of ICUs, and 31% undertook PI research. Although most ICUs were supported by a facility-wide skin integrity service, it was more common in metropolitan ICUs than in rural and regional ICUs (p < 0.001). Conversely, there was greater involvement of occupational therapists in PI prevention in rural or regional ICUs than in metropolitan ICUs (p = 0.026). DISCUSSION AND CONCLUSION: This is the first study to provide a comprehensive description of PI prevention practices in Australian ICUs. Findings demonstrate that PI prevention practices, although nuanced in some areas to geographical location, are used in multiple and varied ways across ICUs.

Incidence and characteristics of hospital-acquired mucous membrane pressure injury: A five-year analysis.

BACKGROUND: Pressure injuries on mucous membranes are caused by pressure from medical devices at the site of injury and differ to those on the skin. Intensive care patients, who have multiple devices in situ, are particularly vulnerable. There is a significant knowledge gap regarding mucous membrane pressure injury (MMPI) incidence in acute hospital settings. AIM: To analyse MMPI incidence and characteristics in a tertiary acute general hospital. METHODS: A secondary data analysis of hospital clinical incident reports was conducted. The sample included all adults with MMPIs between 2015 and 2019. The STROBE reporting guideline was followed. RESULTS: There were 414 reports of MMPI. Most (91.5%, n = 379) were hospital-acquired with the majority found in intensive care patients (74.4%, n = 282). Hospital-acquired MMPI incidence was 0.1% (11 MMPI per 10,000 hospital episodes). In intensive care, the incidence was 2.4% (235 MMPI per 10,000 intensive care episodes). The median time from device insertion until reporting of an MMPI was 3 days. The most common sites of mucosal injury were the lips (35.6%) and mouth (28.8%). In all cases except one, MMPI was associated with medical device use at the site of injury. Five device types were identified (oral endotracheal tube-related 70.3%; urinary catheter 15.5%; gastric tube 8.3%; nasal prongs 3.5%; tracheostomy tube 2.4%). In intensive care, oral endotracheal tube-related devices were most often associated with MMPI (84.8%), whereas in non-intensive care MMPI it was the urinary catheter (51.4%). CONCLUSIONS: While hospital-acquired MMPI incidence is relatively low, it is considerably higher in intensive care patients compared to those in non-intensive care settings. The most common sites are the lips and mouth. RELEVANCE TO CLINICAL PRACTICE: Mucous membrane pressure injuries represent a significant proportion of all hospital-acquired pressure injuries. PATIENT OR PUBLIC CONTRIBUTION: Neither patients nor the public were directly involved in this project.

Use of a Sacral Foam Dressing to Prevent Pressure Injury in At-Risk Subacute Hospitalized Older Adults: A Pilot Randomized Controlled Trial.

PURPOSE: The purpose of this pilot study was to inform a future trial aimed at comparing the effectiveness of a prophylactic sacral dressing plus standard care to standard care only to reduce sacral pressure injuries (PIs) in at-risk older adults admitted to a subacute hospital setting. DESIGN: A pilot study with a pragmatic, open-label, randomized controlled trial design. SAMPLE AND SETTING: One hundred thirty participants were randomized (intervention n = 66, 50.8%; control n = 64, 49.2%). Protocol violations occurred in 48 participants (intervention n = 33, 68.8%; control n = 15, 31.3%). The study setting was a subacute hospital inpatient care unit located in Queensland, Australia. METHODS: Participants were randomly allocated 1:1 to the intervention (prophylactic dressing plus standard care) or control group (standard care). Standard care included regular PI risk and skin assessments, and selection and implementation of preventive interventions (eg, support surfaces and increased repositioning) from a PI prevention care plan. The sacral dressing was applied for intervention participants immediately following recruitment. Ward and research staff collected data and assessed skin integrity daily; participants were followed up until onset of a PI or up to 28 days without PI occurrence. In addition, retrospective chart reviews were undertaken to verify PI occurrences. Patient comfort and dressing utility were also evaluated. RESULTS: Two (3.0%) participants in the intervention group and 1 (1.6%) in the control group developed a sacral PI. The difference was not statistically significant. Only 1 PI was recorded prospectively, while 2 PIs were identified via retrospective chart review. Participants rated dressing comfort highly, particularly during the first 2 weeks, and nurses rated utility highly. Based on the intention-to-treat results, a sample size of 1799 per arm would be required in a definitive trial. CONCLUSIONS: A definitive trial is feasible and warranted. However, the large sample size required in a definitive trial indicates the need for multiple sites.

Translation and piloting of the Chinese Mandarin version of an intensive care-specific pressure injury risk assessment tool (the COMHON Index).

Objective: To translate an intensive care-specific pressure injury risk assessment tool (the COMHON Index) from English into Chinese Mandarin. Methods: A four-step approach to instrument translation was utilised: 1) English-Mandarin forward-translation by three independent bilinguists; 2) Mandarin-English back-translation by two other independent bilinguists; 3) comparison of forward and back-translations, identification of discrepancies, with required amendments returned to step one; and 4) piloting of the translated instrument. The pilot study was undertaken in a Chinese surgical intensive care unit with a convenience sample of 20 nurses. A five-point ordinal scale (1 = very difficult; 5 = very easy) was used to assess ease-of-use and understanding. Translations were retained where medians ≥ 4 indicated use and understanding was easy to very easy. Results: Five iterations of steps 1 to 3, and two sets of amendments to the original English instrument, were required to achieve translation consensus prior to pilot testing. Subscale scoring, sum scoring, and risk categorisation were documented in most pilot assessments (≥ 80%), but three sum scores were incorrectly tallied. The overall tool and all subscales were easy to use and understand (medians ≥ 4), and most assessments (16/20, 80%) took ≤ 5 min to complete. Thus, translations were retained, with minor amendments made to instrument instructions for scoring and risk categorisation. Conclusions: An easy-to-use Chinese Mandarin intensive care-specific pressure injury risk assessment tool has been introduced through cross-cultural translation. However, it requires further testing of interrater reliability and agreement. A rigorous translation and reporting exemplar is presented that provides guidance for future translations.

Systematic review: Incidence and prevalence of mucous membrane pressure injury in adults admitted to acute hospital settings.

Mucous membrane pressure injury (MMPI) is associated with a history of medical device use at the site of injury. The current international guideline recommends they should be reported in incidence and prevalence studies. The aim of this systematic review was to analyse the incidence and prevalence of hospital-acquired MMPI in adults admitted to acute hospital settings. Database searches (EBSCO CINAHL Complete, EBSCO Medline Complete, Embase, Scopus and Web of Science) were undertaken between October 2019 and February 2021, using search terms related to hospital-acquired, mucosal and device-related pressure injury/ulcer incidence and prevalence. Searches were limited to the English language. Articles published between 2008 and 2020, reporting incidence or prevalence of mucous membrane or medical device-related pressure injury in non-interventional samples were selected. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. Twenty-one studies met inclusion criteria; most provided incidence data. No studies were found that specifically reported MMPI incidence or prevalence. It was possible to calculate incidence or prevalence from four studies; all were in intensive care settings. MMPI incidence of 0.8% and 30.4%, and prevalence of 1.7% and 3.7% were found. One study provided data that enabled calculation of prevalence of 0.1% in a non-intensive care sample. Only one other study provided specific data about MMPI. It is concluded that there is insufficient evidence available to enable estimation of MMPI incidence or prevalence in either acute hospital or intensive care settings.

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: The aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings. REVIEW METHOD USED: This is a systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Five databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019. REVIEW METHODS: From an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care-specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate. RESULTS: Overall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I2 = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I2 = 0%) and heel (risk ratio = 0.31, p = 0.02; I2 = 0%) prophylactic dressings for pressure injury prevention. CONCLUSIONS: Only prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care-specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting.

BACKGROUND: Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit. OBJECTIVES: The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations. METHODS: A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist. RESULTS: Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126). CONCLUSIONS: We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

Skin tear prevalence in an Australian acute care hospital: A 10-year analysis.

Hospital-acquired skin tear prevalence is under-reported; thus, the aim of this study was to analyse skin tear point prevalence and characteristics in a tertiary acute care hospital in Queensland, Australia, over a 10-year period. All consenting adult inpatients received a full skin inspection and skin tear category, site, cause, treatment, and whether it was documented as hospital- or community-acquired were recorded. Eleven prevalence audits were analysed with a total sample of 3626 patients. An overall pooled prevalence of 8.9% (95% confidence interval [CI] 7.5-10.4) with an associated hospital-acquired pooled prevalence of 5.5% (95% CI 4.5-6.7) was found. In total, 616 skin tears were reported, of which 374 (60.7%) were hospital-acquired. Over a third of patients (38.7%) had multiple skin tears and most patients (84.8%) with at least one skin tear were aged ≥70 years. The largest proportion of skin tears (40.1%) was those with no skin flap. Of those documented, most were caused by falls or collisions, suggesting combined skin tear and falls prevention strategies may be effective. Over a decade, there was a downward trend in hospital-acquired skin tear, which is encouraging. Skin tear prevalence is recommended as a measure of care quality with an emphasis on good quality documentation.

Effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination. OBJECTIVE: Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019. METHODS: Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data. RESULTS: Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I2 = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I2 = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I2 = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I2 = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I2 = 36%). CONCLUSIONS: Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number:CRD42019129556.