Risk Factors for Hospital-Acquired Pressure Injury in Surgical Critical Care Patients.

BACKGROUND: Hospital-acquired pressure injuries disproportionately affect critical care patients. Although risk factors such as moisture, illness severity, and inadequate perfusion have been recognized, nursing skin assessment data remain unexamined in relation to the risk for hospital-acquired pressure injuries. OBJECTIVE: To identify factors associated with hospital-acquired pressure injuries among surgical critical care patients. The specific aim was to analyze data obtained from routine nursing skin assessments alongside other potential risk factors identified in the literature. METHODS: This retrospective cohort study included 5101 surgical critical care patients at a level I trauma center and academic medical center. Multivariate logistic regression using the least absolute shrinkage and selection operator method identified important predictors with parsimonious representation. Use of specialty pressure redistribution beds was included in the model as a known predictive factor because specialty beds are a common preventive intervention. RESULTS: Independent risk factors identified by logistic regression were skin irritation (rash or diffuse, nonlocalized redness) (odds ratio, 1.788; 95% CI, 1.404-2.274; P < .001), minimum Braden Scale score (odds ratio, 0.858; 95% CI, 0.818-0.899; P < .001), and duration of intensive care unit stay before the hospital-acquired pressure injury developed (odds ratio, 1.003; 95% CI, 1.003-1.004; P < .001). CONCLUSIONS: The strongest predictor was irritated skin, a potentially modifiable risk factor. Irritated skin should be treated and closely monitored, and the cause should be eliminated to allow the skin to heal.

Optimizing Nutrition Care for Pressure Injuries in Hospitalized Patients.

Significance: It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition can lead to longer hospital stays, altered immune function, and impaired skin integrity and wound healing. Malnutrition has been found to be a significant factor influencing pressure injury (PI) risk and wound healing. While PI prevention requires multidimensional complex care using a variety of evidence-based strategies, hospitalized patients benefit from interventions that focus on improving oral nutrition to reduce PI risk and enhance wound healing. Unfortunately, malnutrition is often under-recognized and inadequately managed in hospitalized patients and this can lead to higher rates of complications such as PI. Recent Advances: Recent studies suggest that nutritional care has a major impact in PI prevention and management. Strategies, including early identification and management of malnutrition and provision of specially-formulated oral nutritional interventions to at-risk patients, optimization of electronic health record systems to allow for enhanced administration, monitoring, and evaluation of nutritional therapies, and implementation of protocol-based computerized decision support systems, have been reported to improve outcomes. Critical Issues: Unfortunately, there are gaps in the implementation of nutritional care in hospitals. Timely identification and management of malnutrition is needed to advance quality care for hospitalized patients and reduce malnutrition and associated PI. Future Directions: Further research on effective, evidence-based strategies for implementation of all stages of the nutrition care process is needed to reduce pressure injuries and malnutrition in hospitalized patients.

Pressure Ulcer Prevalence by Level of Paralysis in Patients With Spinal Cord Injury in Long-term Care.

OBJECTIVE: Scientific literature suggests pressure ulcer (PU) risk increases as immobility increases, indicating that more extensive paralysis confers a greater risk of PU. Yet the specific level of paralysis (ie, hemiplegia vs paraplegia vs quadriplegia), apart from neurodegenerative diagnoses, has never been examined in the long-term care (LTC) population. This study examined the prevalence of PU among LTC residents with different paralysis levels. METHODS: The authors conducted a secondary data analysis of the 2012 US Minimum Data Set of LTC facilities (n = 51,664 residents). Measures included PU stage, level of paralysis, functional impairments, comorbidities, and sociodemographic factors. After removing residents with neurodegenerative disease, comatose patients, and those with hip fractures from the analysis, logistic regressions were used to examine the association of risk factors and sociodemographic characteristics with the presence of PU. MAIN RESULTS: The sample included 7,540 patients with quadriplegia, 11,614 patients with paraplegia, and 32,510 patients with hemiplegia in LTC facilities. The PU prevalence in the sample (stages 2, 3, and 4; suspected deep-tissue injury; and unstageable PUs) was 33.9% for patients with quadriplegia, 47.4% for patients with paraplegia, and 9.6% for patients with hemiplegia. CONCLUSIONS: Within paralysis groups (quadriplegic, paraplegic, hemiplegic), risk factors for PU differed in type and magnitude. The PU rates associated with quadriplegia and paraplegia are much higher than LTC residents without paralysis, and PU prevalence for hemiplegia is similar to the rate in LTC residents without paralysis. When the risk factor of paraplegia versus quadriplegia was isolated, PU prevalence for patients with paraplegia was significantly higher.

Research productivity following nursing research initiative grants.

BACKGROUND: In 1995, VA's Office of Research and Development launched the Nursing Research Initiative (NRI), to encourage nurses to apply for research funding and to increase the role of nurse investigators in the VA's research mission. This program provides novice nurse researchers the opportunity to further develop their research skills with the guidance of a mentor. PURPOSE: Since the NRI's inception, its impact on the research career trajectory of budding nurse researchers had never been fully explored. METHODS: An electronic quality improvement survey was developed to collect information about the scope of work and research trajectory of VA nurse researchers undertaken since they received NRI funding. FINDINGS: NRI awardees demonstrated research productivity in several areas including research funding, peer-reviewed publications; participation on journal editorial boards and grant review committees; and mentorship. The majority of past NRI grant recipients (78%) have maintained employment within the VA system and benefit from the expertise, mentoring, and support of other nurse researchers. NRI grant recipients confirm the value of the VA NRI mentored grant funding mechanism and its association with a productive research trajectory with survey respondents demonstrating an average return on investment of $7.7 million in research funding per person. CONCLUSION: The experiences derived from the NRI accelerated the professional growth and research productivity of this group and it guided future opportunities to design, implement, and test nurse-led interventions.

Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans.

This study sought to determine if a parsimonious pressure ulcer (PU) predictive model could be identified specific to acute care to enhance the current PU risk assessment tool (Braden Scale) utilized within veteran facilities. Factors investigated include: diagnosis of gangrene, anemia, diabetes, malnutrition, osteomyelitis, pneumonia/pneumonitis, septicemia, candidiasis, bacterial skin infection, device/implant/graft complications, urinary tract infection, paralysis, senility, respiratory failure, acute renal failure, cerebrovascular accident, or congestive heart failure during hospitalization; patient's age, race, smoking status, history of previous PU, surgery, hours in surgery; length of hospitalization, and intensive care unit days. Retrospective chart review and logistic regression analyses were used to examine Braden scores and other risk factors in 213 acutely ill veterans in North Florida with (n = 100) and without (n = 113) incident PU from January-July 2008. Findings indicate four medical factors (malnutrition, pneumonia/pneumonitis, candidiasis, and surgery) have stronger predictive value (sensitivity 83%, specificity 72%, area under receiver operating characteristic [ROC] curve 0.82) for predicting PUs in acutely ill veterans than Braden Scale total scores alone (sensitivity 65%, specificity 70%, area under ROC curve 0.70). In addition, accounting for four medical factors plus two Braden subscores (activity and friction) demonstrates better overall model performance (sensitivity 80%, specificity 76%, area under ROC curve 0.88).

Prevalence of wet-to-dry dressings in wound care.

OBJECTIVE: This retrospective descriptive study explored the prevalence of wet-to-dry dressings ordered for wound care of open wounds healing by secondary intention. Research questions included the following: How frequently are healthcare providers ordering wet-to-dry dressings for wound care? Which specialties of healthcare providers are most frequently ordering wet-to-dry dressings? Are wet-to-dry dressings being ordered appropriately? METHODS: A retrospective chart review examined admission orders for 202 randomly selected Florida home care and health maintenance organization patients from 2002 to 2004. All subjects in the study had open wounds healing by secondary intention (42 partial-thickness and 160 full-thickness wounds). Frequencies are reported as the main outcome measure. RESULTS: Wet-to-dry dressings accounted for 42% of wound care orders, followed by enzymatic (7.43%) and dry gauze (6.93%). Most wounds treated with wet-to-dry dressings were surgical (69%), followed by neuropathic ulcers (10%) and pressure ulcers (5.9%). Surgical specialists preferred wet-to-dry dressings (73%). Mechanical debridement was not clinically indicated in more than 78% of wounds treated with wet-to-dry dressings. Therefore, wet-to-dry dressings were inappropriately ordered in these cases. CONCLUSIONS: These findings suggest that wet-to-dry dressings (or dry gauze) are prescribed inappropriately in situations where there is little evidence to support their use. To achieve evidence-based practice in wound care, clinical decision making should be scientifically based. Future research should focus on which wound dressings are most effective in optimizing wound healing, as well as on investigating the reasons for the continued use of wet-to-dry dressings.