Our journal was founded in February 1988 by Dr Roberta Abruzzese to gather the latest evidence on pressure injuries (PIs) in one resource for busy clinicians.1 In keeping with this mission, this is our third annual themed issue on PIs. As is fitting for an international journal, our authors come from several countries including China, Iran, and the US. The articles cover a range of PI topics; there are some common themes, and some of the theoretical frameworks described by authors in their articles may be controversial. We have highlighted a few of the articles below to contextualize these advances.
In the continuing education article by Cox and colleagues, they propose a conceptual schema for PIs in critical care patients. After their comprehensive literature review, they separate risk factors into three categories: static intrinsic (eg, older age), dynamic intrinsic (eg, respiratory failure), and dynamic extrinsic (eg, mechanical ventilation). This schema “illustrates complex relationships between risk factor duration and intensity and the underlying etiology of PI development.” They suggest that “focusing on the etiologic bases for PI development… may also provide a framework to explore alternatives to current formal PI risk.”
From California come data about a new proposed PI risk assessment tool. These researchers retrospectively reviewed the data from 406,032 hospital admissions for a 3-year period. From the 1,299 PI cases, they developed a decision tree and selected predictors from the demographic and clinical variables to construct what they have named the Shieh Score. Based on these data, hospital-acquired PIs were more common in men. Several other factors were more than doubled in individuals who developed PIs: length of stay (median, 8 vs 2 days), lower glomerular filtration rate (median 32 vs 66 mL/min), diabetes (57.3% vs 29.9%), and coronary artery disease (32.2% vs 16.0%). These data may serve as a research base for considering other factors in addition to the Braden Scale to prospectively identify patients at highest risk of hospital-acquired PIs.
In their online-only article, Singh and colleagues provide data from their retrospective review of hospital records for a 1-year period in their level 2 US trauma center on community-acquired PIs (CAPIs). There was an increased incidence of CAPI in older adult men with low body mass index. These CAPIs were located on either the sacrum or coccyx and were either at stage 1 or 2. They report that the majority of the injuries had healed prior to discharge.
The articles from Shieh and Singh support earlier research discussing PI risk beyond formal risk assessment scales. For example, two studies by Delmore and colleagues2,3 reported that other independent factors beyond those listed in the Braden Scale (diabetes, vascular disease, perfusion issues, impaired nutrition, age over 65 years, mechanical ventilation, and surgery) should be considered for patients at risk of heel PIs.
The extent of the global PI problem is illustrated in the article by Wang and colleagues. They report PI prevalence and incidence for a 10-year period in their retrospective analysis of patient records in their tertiary hospital in China. From 2009 to 2018, the prevalence increased from 0.19% to 1.00%, increasing with patient age. Further, Qin and colleagues provide data about risk factors for 156 intubated ICU patients over 1 year in their hospital in China. There was an endotracheal (ET) intubation-related PI rate of 23.7%; the most common location was the lip. Factors involved the type of ET intubation, amount of time the ET catheter was in place, catheter fixation, and fixator types (P < .05). Among their conclusions are the importance of early identification of risk factors and interventions to prevent medical device-related PIs.
Finally, knowledge that is based on clinical practice is essential. The significance of nutrition in PI prevention and treatment is highlighted in this issue with a succinct, useful installment of our Practice Points department in a table format (enabler for translation to practice).
This issue (print and online) is jam-packed with new insights into PI prevention, management, and treatment for practice. Through our assemblage of international, interprofessional viewpoints and focus on a variety of aspects of PI care, we hope that our readers are challenged with new concepts to improve patient care.
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
Gary R. Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
1. Abruzzese R. Editorial. Decubitus 1988;1(1):7.
2. Delmore B, Lebovits S, Suggs B, Rolnitzky L, Ayello EA. Risk factors associated with heel pressure ulcers in hospitalized patients. J Wound Ostomy Cont Nurs 2015;42(3):242–8.
3. Delmore B, Ayello EA, Smith D, Chu AS, Rolnitzky L. Refining heel pressure injury risk factors in the hospitalized patient. Adv Skin Wound Care 2019;32(11):512–9.