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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 (r s ) 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., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

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., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

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., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

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)., (© 2021 John Wiley & Sons Ltd.)

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., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

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., (Copyright © 2022 by the Wound, Ostomy and Continence Nurses Society.)

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, I 2  = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I 2  = 0%) and heel (risk ratio = 0.31, p = 0.02; I 2  = 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., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

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., Competing Interests: Conflict of interest None., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

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., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

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, I 2  = 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, I 2  = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I 2 = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I 2  = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I 2 = 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., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Pressure injury is recognised as an adverse event occurring in healthcare settings. Patients in intensive care are at high risk of developing a pressure injury. Cardiac patients are also among those at higher risk., Objectives: To systematically assess the incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care., Design: Systematic review and meta-analysis of incidence and prevalence REVIEW METHODS: Articles published in English between 2009 and 2018, reporting pressure injury as a primary outcome were selected based on inclusion criteria. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. A random effects meta-analysis was conducted. Sub-group meta-analyses were conducted to investigate potential causes of heterogeneity., Results: Fifteen studies met the criteria for inclusion in the systematic review, of which 14 were incidence studies. Heterogeneity was significant and there was large observed variance between studies. The 95% confidence interval of cumulative incidence across all 14 studies, with an overall sample size of 6371, was 9.8-25.6%. In 11 studies that included all-stage pressure injury the 95% confidence interval was 8.3-28.3%. In seven studies in which Stage 1 pressure injury was excluded, the 95% confidence interval was 5.8-22.7%. In the single prevalence study included, which excluded Stage 1 pressure injury, prevalence was 8.8%., Conclusions: The incidence of pressure injury in cardiac intensive care patients was similar to that found in general intensive care patients. However, our results suggest that the incidence may be significantly higher in cardiac surgical patients admitted to intensive care. There were significant differences across the various studies in the ways in which data were collected and reported. Further well-designed studies are required to better understand incidence in this population, using standardised methods of data collection and reporting., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Formal assessment by nurses of a patient's pressure injury (PI) risk level is often highlighted as being key to PI prevention. However, if no action is taken to address the determined risk (i.e., if appropriate preventative interventions are not implemented), the patient remains vulnerable to PI development, and the assessment process is rendered pointless., Aim: To explore the relationship between the prescription (planning) and implementation of PI preventative interventions by nurses following formal risk assessment., Methods: Using an exploratory, descriptive design, the charts and bedside areas of 200 adult patients admitted across four hospital wards were examined. Data collected included PI risk level, documented prescribed preventative interventions, and interventions for which there was evidence of implementation., Results: Of the final sample (n = 187), 66.8% of cases were categorized as being "at-risk" or above. As the risk category of patients increased, proportionately more patients in each category were prescribed each intervention. However, in most cases, significantly fewer interventions were actually implemented than were prescribed, except for several interventions that were implemented in more cases than were prescribed. There were 14 cases, including four at-risk and three high-risk patients, in which no preventative interventions were prescribed, while 88.7% of not at-risk patients had (unnecessary) preventative interventions prescribed., Discussion: These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. The results indicate a significant mismatch between these two steps of PI prevention., Linking Evidence to Action: These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. A significant mismatch between these two steps of PI prevention was evident. Following patient risk assessment, there should be a greater focus on appropriate preventative intervention prescription (planning) with regular review and audit to help ensure that interventions are implemented as prescribed. Improved implementation of preventative interventions should, in turn, help to reduce hospital-acquired pressure injuries., (© 2020 Sigma Theta Tau International.)

The aim of this modified Delphi study was to determine a minimum pressure injury preventative intervention set for implementation relative to critically ill patients' risk level. Preventative interventions were identified via systematic review, risk levels categorised by an intensive-care-specific risk-assessment-scale (COMHON Index), and panel members (n = 67) identified through an international critical care nursing body. Round 1: panel members were asked to rate implementation of 12 interventions according to risk level (low, moderate, high). Round 2: interventions were rated for use at the risk level which received greatest round 1 support. Round 3: interventions not yet achieving consensus were again rated, and discarded where consensus was not reached. Consensus indicated all patients should receive: risk assessment within 2-hours of admission; 8-hourly risk reassessment; and use of disposable incontinence pads. Additionally, moderate- and high-risk patients should receive: a reactive mattress support surface and a heel off-loading device. High-risk patients should also receive: nutritional supplements if eating orally; preventative dressings (sacral, heel, trochanteric); an active mattress support surface; and a pressure-redistributing cushion for sitting. Repositioning is required at least 4-hourly for low-risk, and 2-hourly for moderate- and high-risk patients. Rigorous application of the intervention set has the potential to decrease pressure injuries in intensive care., (© 2020 Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: Pressure injury can cause significant patient physical pain, impact quality of life for individuals and their families, and increase hospital length of stay and healthcare costs. Within the hospital setting, it is considered to be largely preventable and regarded as an adverse event. In this context, prophylactic use of a protective sacral dressing to prevent pressure injury has been investigated by various researchers., Objectives: Analyse the effectiveness of prophylactic sacral protective dressings to prevent pressure injury., Design: Systematic review and meta-analysis of randomised controlled trials., Data Sources: Electronic database searches were undertaken in 2018 and 2019. Initial searches identified 557 articles. Following duplicate removal and screening, 49 full text articles were reviewed. Most were excluded, leaving six studies that met the criteria for full review., Review Methods: Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. A random effects meta-analysis was conducted using sample sizes based on intention-to-treat analysis. Sub-group meta-analyses were conducted of three studies in the intensive care setting and four studies that used the same dressing., Results: Overall, the six randomised controlled trials were judged to be of moderate quality. Due to visibility of the intervention, blinding was rare. Five studies were described as intention-to-treat; however two of these presented per-protocol analyses. All studies compared the intervention plus standard care to standard care. Five studies demonstrated statistically significant reduced pressure injury incidence in the intervention group. All studies were included in the meta-analysis (total n = 1872) and demonstrated homogeneity (I 2  = 10%). Meta-analysis revealed an overall effect in favour of the intervention [risk ratio (RR) = 0.30, 95% CI 0.17-0.51] with a 95% prediction interval of 0.11-0.80. Sub-group analyses of intensive care studies and those using the same dressing demonstrated positive effects (RR = 0.17, 95% CI 0.06-0.49, I 2  = 0%, and RR = 0.32, 95% CI 0.13-0.764, I 2  = 31%; respectively)., Conclusions: The meta-analysis provides moderate evidence of the effectiveness of a prophylactic sacral dressing to prevent pressure injury, with an overall relative risk indicating that the intervention decreases pressure injury risk by 70%. Sub-group analysis of intensive care studies demonstrated a large relative risk reduction of 83% suggesting the dressing may be more effective in this high-risk group. The lower relative risk reduction of 68% found in four studies using the same dressing, in which there was moderate heterogeneity, indicates that further research is needed to clarify dressing choice., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Pressure injuries are harmful, painful, and potentially preventable. Although hospital-acquired pressure injury prevalence is decreasing, it is unclear if some pressure injuries develop before hospital admission. The objective of this study was to investigate the prevalence of pressure injury in adults on arrival by ambulance to the emergency department (ED)., Methods: An observational, cross-sectional descriptive study design was used. Participants (n = 212) were recruited from the EDs of two Australian tertiary hospitals. Full skin inspection and pressure injury risk assessment, using Braden and Waterlow scores, were undertaken within 1 h of presentation., Results: Pressure injuries were identified in 11 of 212 participants, giving a prevalence of 5.2% at presentation. Nearly all were admitted to hospital, giving a prevalence of 7.8% at this entry point. Participants with pressure injury and those at high risk of injury were found to have spent longer in the ambulance and within the ED. During ambulance transport and in the first hour of presentation to the ED, it was rare that pressure-relieving interventions were implemented, even for those with an identified pressure injury and those at high risk., Conclusions: The results indicate that early pressure injury surveillance and risk assessment are merited at the point of presentation to the ED, so that prevention and treatment can be implemented at the earliest possible opportunity. Although it is more challenging to manage pressure injuries within the ambulance and ED, the use of pressure-relieving devices should be considered for those at greatest risk. Further research is recommended., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to assess nurses' knowledge of pressure injuries in order to gather benchmark data, identify knowledge gaps, and based on results, implement educational strategies to improve practice., Design: Cross-sectional survey., Subjects and Setting: The study setting was a large Australian tertiary general hospital employing approximately 2500 nurses in both full-time and part-time roles. A proportional sample (25%) stratified by experience, preparation, and facility-generated categories (nursing grade) was generated. The sample included nursing students and nursing assistants. Three hundred six participants completing the survey., Instrument: The Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZPUKT) version 2, comprising 72 statements, with 3 subscales (prevention/risk, staging, and wound description) was used to measure pressure injury knowledge. Item responses are "True," "False," and "Don't know." For the purpose of analyses, correct responses were scored 1, and incorrect or "don't know" responses were scored 0. Generally accepted ranges of scoring for the original PZPUKT specify less than 70% as unsatisfactory, 70% to 79.9% as satisfactory, 80% to 89.9% as good, and 90% and greater as very good knowledge of pressure injury prevention., Methods: The survey was advertised throughout the hospital by strategically placed posters, computer screen savers within the hospital, and e-mails. Respondents completed paper-based questionnaires and data were manually entered online. Data were collected between September 2015 and October 2016. Descriptive and nonparametric inferential statistical tests (Mann-Whitney U, Kruskal-Wallis H) were used to analyze within sample differences in scores., Results: The overall mean knowledge score was 65%; approximately two-thirds of the sample (68%) scored 60% and greater, reflecting an unsatisfactory knowledge level of pressure injury prevention according to the original PZPUKT scores. The lowest mean scores were found in the "wound description" subscale. Participants who sought pressure injury information via the Internet or had read pressure injury guidelines scored significantly higher than those who did not (P = .001 and P < .001, respectively). Seventeen items were answered incorrectly by over half of participants, identifying important knowledge deficits, particularly within the wound description subscale., Conclusions: When compared with results from studies using the PZPUKT, we contend that a cutoff score of 60% and greater (instead of ≥70%) should be used to indicate an overall satisfactory score. Our results identified deficits in pressure injury knowledge related to seating support and seated individuals and wound dressings as areas where nurses would benefit from focused education strategies.

Objective: Hospital-acquired pressure ulcers (PU) continue to occur despite an ongoing focus on prevention. The aim of this review was to identify and evaluate primary research which links pressure ulcer risk assessment with prescription and implementation of preventative interventions for hospitalised adults., Method: A systematic review of the databases EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus and Web of Science was undertaken, using search terms related to pressure ulcers, hospital-acquired, risk, planning, implementation, prevention and outcome. Primary research reports that linked PU risk assessment with prescription and implementation of preventative interventions in some way were included., Results: From 589 potentially eligible publications, 20 primary research reports were included. Of these, seven linked PU risk assessment to preventative intervention implementation and 13 linked it to preventative intervention prescription and implementation in some way. No studies linked PU risk assessment to preventative intervention prescription alone., Conclusion: While the included studies linked these components in some way, there was little focus on the relationship between the three. PU preventative intervention prescription is not well defined, with inconsistencies noted in intervention prescription across studies. Many studies reported inadequate provision of prevention measures for patients at risk of PU. Further research is required to explore the relationship between PU risk assessment and preventative intervention prescription alone, and with implementation.

This exploratory, descriptive study aimed to identify and describe the pressure injury preventative interventions prescribed by nurses following the assessment of a patient's pressure injury risk and to compare the prescribed interventions relative to the assessed risk level. A total of 200 inpatients in a tertiary Australian hospital were included. Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. Most patients were assessed as not being at risk, with the largest group of at-risk patients assessed as being at high risk. Some not-at-risk patients were prescribed interventions intended for those at risk, while prescription rates of preventative interventions recommended for those at any level of risk were variable (6%-64%). Significant associations were found between assessed pressure injury risk and preventative intervention prescription. Preventative intervention prescription was inadequate, potentially exposing some patients to pressure injury. However, the association between intervention prescription and risk level suggests that nurses are prescribing interventions relative to risk. A more structured approach to intervention prescription according to risk level, such as a care bundle, may help to improve nurses' preventative intervention prescription and ensure that all at-risk patients receive appropriate preventative interventions., (© 2018 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Pressure injuries contribute significantly to patient morbidity and healthcare costs. Critically ill patients are a high risk group for pressure injury development and may suffer from skin failure secondary to hypoperfusion. The aim of this study was to report hospital acquired pressure injury incidence in intensive care and non-intensive care patients; and assess the clinical characteristics and outcomes of ICU patients reported as having a hospital acquired pressure injury to better understand patient factors associated with their development in comparison to ward patients., Methods: The setting for this study was a 630 bed, government funded, tertiary referral teaching hospital. A secondary data analysis was undertaken on all patients with a recorded PI on the hospital's critical incident reporting systems and admitted patient data collection between July 2006 to March 2015., Results: There were a total of 5280 reports in 3860 patients; 726 reports were intensive care patients and 4554 were non-intensive care patients, with severe hospital acquired PI reported in 22 intensive care patients and 54 non-intensive care patients. Pressure injury incidence increased in intensive care patients and decreased in non-intensive care patients over the study period. There were statistically significant differences in the anatomical location of severe hospital acquired pressure injuries between these groups (p=0.008)., Conclusion: Intensive care patients have greater than 10-fold higher hospital acquired pressure injury incidence rates compared to other hospitalised patients. The predisposition of critically ill patients leaves them susceptible to pressure injury development despite implementation of pressure injury prevention strategies. Skin failure appears to be a significant phenomenon in critically ill patients and is associated with the use of vasoactive agents and support systems such as extra corporeal membrane oxygenation and mechanical ventilation., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Hospital-acquired pressure injury is associated with increased morbidity and mortality and considered to be largely preventable. Pressure injury prevalence is regarded as a marker of health care quality., Objective: To compare the state-wide prevalence, severity and location of pressure injuries of intensive care unit patients compared to patients in non-intensive care wards., Method: The study employed a secondary data analysis design to extract and analyse de-identified pressure injury data from all Queensland Health hospitals with level I-III intensive care facilities that participated in Queensland Bedside Audits between 2012-2014. The sample included all adult ICU and non-ICU patients that provided consent for the Queensland Bedside Audits, excluding those in mental health units., Results: Excluding Stage I, overall hospital-acquired pressure injury prevalence from 2012 to 2014 was 11% for intensive care patients and 3% for non-intensive care patients. Intensive care patients were 3.8 times more likely (RR 2.7-5.4, 95% CI) than non-intensive care patients to develop a pressure injury whilst in hospital. The sacrum/coccyx was the most common site of hospital-acquired pressure injury in all patients (intensive care patients 22%; non-intensive care patients 35%) however, mucosal pressure injury proportion was significantly higher in intensive care patients (22%) than in non-intensive care patients (2%). Stage II HAPI prevalence was the most common stage reported, 53% for intensive care patients compared to 63% for non-intensive care patients., Conclusion: There are significant differences in hospital-acquired pressure injury prevalence by stage and location between intensive care and non-intensive care patients reflecting the possible impact of critical illness on the development of skin injury. This has implications for resource funding for pressure injury prevention and the imposition of government initiated financial penalties for hospital-acquired pressure injury. For future comparisons to be effective between intensive care units, benchmarking partners should share similar characteristics and relevant targets., (Copyright © 2016 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Aim: To test the psychometric properties of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index., Background: Pressure injury risk assessment is a crucial aspect in determining the relative risk of patients and the need for preventative intervention. In the intensive care setting there are few risk assessment scales that have been developed specifically for critically ill patients., Design: Instrument development., Methods: A convenience sample of 26 intensive care patients was used. Data were collected in December 2012. Five intensive care nurses scored each patient with all four scales. Intraclass correlation coefficients and standard errors of measurement were used to assess inter-rater reliability and agreement of the sum, risk category and item scores. Convergent validity of the COMHON Index was investigated by examining correlations between the sum scores and similar constructs of the scales., Results: Inter-rater reliability of the COMHON Index was higher than the other scales and strong correlations were found between it and the Braden and Norton scales but not the Waterlow score. Two items common to all scales (mobility; neurological status) demonstrated significant correlations between the COMHON, Braden and Norton scales but not the Waterlow score. One item (nutrition) was significantly correlated between the COMHON and Braden scales., Conclusion: Inter-rater reliability and agreement of the COMHON Index were the highest of the four scales, with the Norton and Braden performing similarly and the Waterlow score the least well. The strong and significant associations between the Braden, COMHON and Norton scales suggest they are measuring similar constructs., (© 2015 John Wiley & Sons Ltd.)

Purpose: Management of hospital-acquired pressure ulcers (PUs) is an essential aspect of nursing practice that requires knowledge of risk assessment, prevention, identification, and treatment strategies. The aim of this study was to assess nurses' knowledge of PU management in order to identify knowledge gaps., Subjects and Setting: The study setting was a large Australian health service district employing more than 10,000 nurses in full and part-time roles. A proportional (by facility) and stratified (by nursing grade) sample of 10% of the district population was targeted. Eight hundred twenty-seven participants completed the survey. Most participants had more than 5 years of experience as professional nurses., Design: Cross-sectional survey., Instrument: A modified version of the Pressure Ulcer Knowledge Test, comprising 49 true/false questions, was used. A cutoff score of 90% of participants answering an item correctly was used to gauge "adequate" knowledge level., Methods: An opportunity to participate in the research was advertised throughout the different facilities in the district by strategically placed posters, computer screen savers, and e-mails. Most data were collected online, with some collected manually using paper-based questionnaires. All data were collected between April and November 2012., Results: Twenty-six questions (53%) were answered correctly by 90% or more of participants, and 6 questions were answered correctly by 50% or less, identifying important knowledge deficits. The mean Pressure Ulcer Knowledge Test score was 79%; 15 nurses (1.8%) achieved a score of 90% or more, and more than 90% achieved scores more than 70%. There were small but significant positive effects of years of nursing experience and level of nursing grade on the knowledge scores., Conclusions: Our results identified deficits in PU knowledge and areas where nurses would benefit from focused education strategies.

To prevent pressure injuries research indicates the importance of focusing on three key areas of practice: continence, skin hygiene and nutrition. These are a synergistic trio and many patients require considered management in all three areas. In addition to targeting specific aspects of nursing care in these areas, it is also crucial that there is organisational buy-in for strategic initiatives. Some of the ways that we achieved this are outlined below: Support from managerial level by presenting evidence and education to senior nurses and directors. Nurse unit managers completed individual ward action plans outlining their individual commitments to reducing pressure injuries. Providing support and education to staff to choose and use continence products effectively. Support from allied health colleagues in prevention of pressure injuries. After implementing the actions described above, pressure injury prevalence at the Prince Charles Hospital in Brisbane decreased from 13.78% in 2008 to 5.15% in 2010, representing a 62% reduction overall. Of these pressure injuries, 53% were stage one.

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

Aim Design Methods Results Conclusion Impact Reporting Method Patient/Public Contribution Implications for the profession and/or patient care 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.Interrater agreement study.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.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.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.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.This study adhered to the GRRAS reporting guideline.No patient or public involvement in this study.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. [ABSTRACT FROM AUTHOR]