Hospital-acquired pressure injuries (HAPIs) are mostly preventable but occur with depressing regularity, especially in vulnerable patient populations like diabetics or the obese. In this context, stringent prevention protocols, possibly including multi-layer foam dressings, are a must.

HAPIs are linked to poorer health outcomes, a lower quality of life, and higher healthcare expenses

Acute and critically ill patients tend to suffer from hospital-acquired pressure injuries (HAPIs), which are prevalent, expensive, and often fatal. Any area of skin or underlying tissue that has been damaged because of intense or sustained pressure combined with shear is referred to as a pressure injury (PI). Shear involves two adjoining internal body parts (such as bone, muscle, fat) that distort in the horizontal plane of the body. Measurement of shearing force and its relationship

to PI development has not been fully established. Friction, which includes the rubbing of a body part with another or against another material element, is commonly included when considering the impact of shear on PI.

Microscopic examination of tissue after one hour of pressure application demonstrates cellular infiltration, extravasation, and hyaline degeneration, with muscle necrosis and venous thrombosis occurring with higher pressure for longer periods of time. Pressure injuries are common among the aged and fragile, and they are linked to an increased risk of morbidity and death. Due to variables such as aging, age-related skin changes, chronic illnesses that limit peripheral blood supply and tissue tolerance to pressure, starvation, immobility, incontinence, cognitive impairment, and complicated comorbidities, the elderly are at a higher risk of acquiring HAPIs.

HAPIs are linked to poorer health outcomes, lower quality of life, and higher healthcare expenses. As the severity of the damage grows, so does the impact on the patient and the cost. Patients with a HAPI are 2.8 times more likely to die during their hospital stay (p.001) and 1.69 times more likely to die within 30 days of release (p.001), and they experience substantial pain and suffering, delayed functional recovery, and an extended hospital stay.

Poor compliance with turning guidelines and varied rates of pressure injuries (3%–37%) have been found in studies evaluating patient turning around the world. Older age, immobility, changed mental state, urinary or faecal incontinence, hospitalisation for fracture, surgical intervention, reduced appetite, and nasogastric tube or intravenous nutrition are all risk factors for developing an HAPI.

Pressure injuries may be prevented, according to research. A variety of therapies have been researched, with various degrees of success. Pressure injury risk identification and risk mitigation are two linked domains in the method for preventing pressure injuries. A variety of risk assessment tools are used to determine whether or not a patient is at risk of acquiring a pressure injury. Norton, Waterlow, Braden, and the interRAI Pressure Injury Risk Scale are among these tools. According to current studies, no single tool appears to be superior to the others. In estimating pressure injury risk, the Braden and Norton risk assessment instruments appear to be more accurate than nurses’ clinical judgment.

RISK FACTORS

Risk factors identified by the risk assessment should be addressed in interventions that are tailored to the patient’s specific requirements. Pressure alleviation, specialised mattresses, dressing over bony prominences, monitoring systems, nutritional support, and the use of skin moisturizers are some of the interventions.

Tissue tolerance, defined as the skin’s and supporting structures’ ability to withstand pressure without complications, is a key factor in assessing a patient’s risk of HAPIs. Moisture, measured as

incontinence, excessive moisture or oedema or via the moisture Braden subscore, is a significant predictor of HAPIs and patients exhibiting excessive moisture, via diaphoresis, incontinence or weeping oedema, are known to be at an increased risk for HAPI.

HAPIs are strongly predicted by the unit type patients are admitted into. Patients who spend time in the ICU or were admitted to a surgical unit are more likely to develop HAPIs. Nurse staffing, as defined by hours per patient day (HPPD), skill mix, and expertise are all significant predictors of HAPI development. Higher HPPD was linked to a reduced risk of HAPIs, whereas a higher skill mix was linked to a lower risk of HAPIs.

Non-blanchable erythema is a marker of pressure ulcer damage in its early stages. If a person with pre-existing non-blanchable erythema is positioned directly onto bony prominences, the pressure and/or shearing forces encountered will further obstruct the blood supply to the skin, increasing the damage and leading to more serious pressure ulceration.

Comprehensive skin examination

To prevent HAPIs, a patient’s entire skin must be evaluated for any anomalies via a comprehensive skin assessment. This necessitates examining and feeling the skin from head to toe, with a focus on bony prominences. Comprehensive skin examination serves a number of essential aims and operates as the first step in preventing pressure ulcers. These include recognising any existing pressure ulcers and assessing whether there are any other lesions or skin-related variables that predispose to the formation of pressure ulcers, such as extremely dry skin.

A comprehensive skin assessment is not a one-time occurrence that occurs only during admission. It should be done on a frequent basis to see whether there have been any changes in the skin’s state. A full skin examination should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge in most hospital settings. It may, however, be done as regularly as every shift in some contexts. When you arrive in the emergency room, operating room, or recovery room, the admission examination is especially critical.

Pressure injury risk assessment

Following a comprehensive skin examination, a pressure injury risk assessment is the next step in preventing pressure ulcers. Pressure injury risk assessment is a structured and continuing approach that identifies patients who are at risk of developing a pressure ulcer so that plans for focused preventive care can be implemented to address the identified risk. A validated risk assessment instrument or scale is one of the many components of this intricate procedure.

Consider doing a risk assessment on admission and thereafter daily or if there is a major change in condition in general acute care settings. Pressure ulcer risk can vary rapidly, especially in acute care settings. As a result, suggestions for risk assessment frequency will differ. Risk assessment should be undertaken more frequently, such as every shift, in environments where patients’ status may change quickly, such as critical care. For surgeries lasting more than 4 hours, there are recommendations to assess on admission, at discharge to the recovery room, and on a regular basis in the OR.

Risk assessment scales

Risk assessment scales are a standardised means of examining some of the elements that may put a person at risk of developing a pressure ulcer. According to research, these methods are particularly useful in identifying people who are at low to moderate risk, whereas nurses can identify persons who are at high risk or have no risk. All risk assessment scales should be used in conjunction with a thorough examination of a person’s other risk variables as well as sound clinical judgment.

While some institutions have developed their own instruments, the Norton Scale and the Braden Scale are two risk assessment measures that are commonly utilised in the broader adult population. Both the Norton and Braden scales have been proven to be reliable and valid. The Norton Scale consists of five subscales (physical condition, mental condition, activity, mobility, and incontinence) that are rated on a scale of 1 to 4. (1 for a low level of functioning and 4 for the highest level of functioning). The subscales are combined for a total score ranging from 5 to 20. A lower Norton Scale score suggests an increased chance of developing a pressure ulcer. At-risk status is often indicated by a score of 14 or less.

The Braden Scale is made up of six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction/shear) that are rated from 1 to 4 or 1 to 3 on a scale of 1 to 4. (1 for low level of functioning and 4 for the highest level or no impairment). The total number of points ranges from 6 to 23. A lower Braden Scale score indicates a greater risk of developing a pressure ulcer. At-risk status is often indicated by a score of 18 or less. This level may need to be altered depending on the patient demographic on your unit or the hospital’s policies.

TREATMENT STRATEGY

Preventing HAPIs necessitates a multidisciplinary approach to treatment. Some aspects of HAPI preventive therapy are highly regimented, but care must also be personalized to each patient’s unique risk profile. Regardless of how skilled a physician is, no single doctor can prevent all pressure ulcers from occurring. Instead, pressure injury prevention necessitates the participation of many people, including the various disciplines and teams involved in establishing and implementing the treatment plan.

Repositioning a person is done to help with comfort, hygiene, dignity, and functional capacity by reducing the length and severity of pressure on susceptible parts of the body. For certain people, regular positioning is impossible due to a medical condition, hence an alternative preventative technique, such as supplying a high-specification mattress or bed, may be necessary. When deciding on a position for an individual, it’s critical to consider if the pressure is being relieved or redistributed.

Foam dressings

The administration of preventive dressings to the sacral area has been shown to help avoid the formation of pressure ulcers there. Mechanical cushioning, the lowering of shear pressures inside soft tissues, and a lower friction coefficient between the dressing and the support surface are all modes of action for HAPI preventative dressings. There are many different types of dressings on the market, and in vitro studies show that they may have varied impacts on the skin microclimate, pressure reduction, and possibly clinical outcomes.

There are various comparative in vitro studies that examine the ability of the main dressings on the market in terms of pressure redistribution, liquid/hydration management, and friction application, which are the primary variables in the onset of HAPIs. Polyurethane foam, especially in multiple layers, appears to be the most effective material overall. The use of multi-layer foam dressings was found to be a successful technique of preventing HAPIs in two recent clinical trials of patients referred to the intensive care unit (ICU).

According to some studies, using multi-layer polyurethane foam dressings shaped for the sacrum area in conjunction with normal preventive treatment can help prevent HAPIs. A recent randomised trial found that employing multi-layer polyurethane foam dressings in the sacrum region dramatically reduces the rate of PU by 10.9 per cent when paired with standard preventative care (8 vs 28; P =.001), presumably due to a redistribution of the foam’s mechanical forces.

Despite a 22 % increase in patient load, the incidence of HAPIs in an adult intensive care unit was reduced by 69 % (n = 17; 3 % of patients in 2013 vs n = 45, 10 % of patients in 2011) in a study to assess the effectiveness of a formal, year-long HAPI prevention program including multi-layer foam dressings with the goal of achieving at least a 50 % reduction over the course of a year. The potential cost savings because of this reduction was estimated to be approximately $1 million (R15.5 million).

When it comes to foam dressings, various international guidelines recommend using foam dressings on exuding Category/Stage II and shallow Category/Stage III pressure ulcers and avoiding using single small pieces of foam in exuding cavity ulcers. Wound care specialists should also consider using gelling foam dressings in highly exuding pressure ulcers.

CONCLUSION

HAPIs are a serious problem in the wound care hospital setting, especially among vulnerable populations such as diabetic or obese patients. This is especially pertinent in the South African context since we have a high rate of patients at risk of HAPIs due to the prevalence of co-morbidities such as diabetes that make them more susceptible. Simple preventative measures such as frequent repositioning of patients helps, but this works best in conjunction with dressings such as the multi-layer foam dressings often found to act as preventatives.

REFERENCES

Berlowitz, D, et al, 2019. Preventing Pressure Ulcers in Hospitals. Agency for Healthcare Research and Quality, 2019, US Department of Veterans Affairs: Washington.

Forni, C, et al, 2017. Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial. Int Wound J. 2018;15:383–390.

Kayser, S, et al, 2018. Prevalence and Analysis of Medical Device-Related Pressure Injuries: Results from the International Pressure Ulcer Prevalence Survey. Adv Skin Wound Care. 2018 Jun; 31(6): 276–285.

Lechner, A, et al, 2020. Comparing the effects of three different multilayer dressings for pressure ulcer prevention on sacral skin after prolonged loading: An exploratory crossover trial. Wound Rep Reg. 2021;29:270–279.

Padula, WV, 2017. Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent Hospital-Acquired Pressure Injuries in Acute Care Hospitals: An Observational Cohort Study. J Wound Ostomy Continence Nurs. 2017 Sep; 44(5): 413–419.

Padula, WV, et al, 2018. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019;16:634–640.

Santamaria, N, et al, 2018. A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial. Int Wound J. 2018;15:482–490.

Tschannen, D, et al, 2020. The pressure injury predictive model: A framework for hospital-acquired pressure injuries. J Clin Nurs. 2020;29:1398–1421.