Examining Prevalence and Risk Factors of Incontinence-Associated Dermatitis Using the International Pressure Ulcer Prevalence Survey.

PURPOSE: To evaluate prevalence and risk factors of incontinence-associated dermatitis (IAD). DESIGN: Retrospective analysis of 2016 International Pressure Ulcer Prevalence survey data. SUBJECTS AND SETTING: Adult patients who were in acute care, long-term acute care, long-term care, and rehabilitation facilities in the United States and Canada. METHODS: IAD prevalence was calculated among all patients surveyed, among the incontinent patients only, across multiple care settings, and by incontinence type. A logistic regression examined risk factors for IAD in the incontinent population. RESULTS: Nearly 1 in 5 incontinent patients had IAD documented. Incontinence-associated dermatitis prevalence in the entire patient population was 4.3% while incontinence prevalence was 18%. Of incontinent patients, prevalence of IAD ranged from 8.4% in long-term care facilities to 19% in acute care facilities. Facilities with higher rates of incontinence did not necessarily have higher prevalence of IAD. Incontinence-associated dermatitis prevalence by incontinence type ranged from 12% for patients with urinary incontinence to 26% for patients with fecal management systems. Regression results support the association of the following factors with an increased likelihood of IAD documented: all types of incontinence, fecal management systems, higher body weight, diminished mobility, additional linen layers, longer length of stay, and lower Braden Scale scores. CONCLUSIONS: Incontinence-associated dermatitis remains a concern in acute care settings. Risk factors associated with IAD were similar to risk factors previously reported for hospital-acquired pressure injuries, such as limited mobility, longer lengths of stay, and additional linen layers. By consistently documenting IAD as well as pressure injury prevalence, facilities may benchmark overall skin prevention models.

Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey.

BACKGROUND: Prevalence of hospital-acquired pressure injuries has declined over time. However, it is unknown if this decline is consistent for different stages of pressure injuries. It is also unknown if risk factors differ between superficial (stage 1 and 2) and severe (stage 3, 4, deep tissue, and unstageable) pressure injuries. OBJECTIVE: To examine changes in prevalence of superficial and severe hospital-acquired pressure injuries from 2011 to 2016. To evaluate differences between risk factors associated with superficial versus severe hospital-acquired pressure injuries. DESIGN: Retrospective analysis of the 2011-2016 International Pressure Ulcer Prevalence™ data. SETTING: Acute care hospitals in the USA. PARTICIPANTS: 216,626 patients had complete data. METHODS: Prevalence of all, superficial, and severe hospital-acquired pressure injuries was calculated annually from 2011 to 2016 and linear trendlines were generated. Two logistic regressions examined risk factors for superficial and severe hospital-acquired pressure injuries. RESULTS: Prevalence of superficial hospital-acquired pressure injuries declined significantly from 2011 to 2016. However, prevalence of severe pressure injuries did not show a reduction. Risk factors that significantly increased the risk of both superficial and severe pressure injuries were: increased age, male gender, unable to self-ambulate, all types of incontinence, additional linen layers, longer lengths of stay, and being in an intensive care unit. Body mass index (BMI) had a U-shaped relationship, where the likelihood of having either type of pressure injury was highest for low and high BMIs. CONCLUSIONS: A decline in superficial, but not severe, hospital-acquired pressure injuries suggests current prevention techniques might not adequately prevent severe pressure injuries. Generally, risk factors for superficial and severe pressure injuries were highly similar where all 14 of the risk factors were significant in both regression models. However, five risk factors in particular - ICU stay, presence of an ostomy, patient age, ambulatory status, and presence of a fecal management system - had substantially different effect sizes.

Prevalence and Analysis of Medical Device-Related Pressure Injuries: Results from the International Pressure Ulcer Prevalence Survey.

OBJECTIVE: To examine the prevalence and characteristics of medical device-related pressure injuries (MDR PIs) in a large, generalizable database. METHODS: This study is a retrospective analysis of the 2016 International Pressure Ulcer Prevalence data. Data were limited to US and Canadian facilities. Facilities included acute care, long-term care, rehabilitation, long-term acute care hospitals, and hospice. Analysis included 102,865 adult patients; 99,876 had complete data and were the focus of the analysis and are reported in the results below. RESULTS: The overall PI prevalence was 7.2% (n = 7189), and the facility-acquired prevalence was 3.1% (n = 3113). The prevalence of MDR PIs was 0.60% (n = 601), which included both mucosal and nonmucosal MDR PIs. In this study, 75% of MDR PIs were facility acquired, whereas non-MDR PIs were most commonly present on admission. Facility-acquired MDR PIs formed 3 days faster than facility-acquired non-MDR PIs (12 vs 15 days; P < .05). By stage, most MDR PIs were superficial (58% were Stage 1 or 2), 15% were deep-tissue PIs, and 22% were full-thickness PIs (Stage 3 or 4 or unstageable). The most common anatomic locations for MDR PIs were the ears (29%) and the feet (12%). The most common devices associated with MDR PIs were nasal oxygen tubes, 26%; other, 19%; cast/splints, 12%; and continuous positive airway pressure/bilevel positive airway pressure masks, 9%. CONCLUSIONS: Because MDR PIs form faster than non-MDR PIs, timely proactive assessment and prevention measures are critical. Most MDR PIs occurred at the face and head region, and the ears specifically. The most common devices linked with MDR PIs were oxygen tubing and masks, making assessment and prevention efforts critical for patients who require those devices.

The International Pressure Ulcer Prevalence™ Survey: 2006-2015: A 10-Year Pressure Injury Prevalence and Demographic Trend Analysis by Care Setting.

PURPOSE: Measurement of pressure injury (PI) prevalence allows benchmarking within and across facilities; the International Pressure Ulcer PrevalenceTM (IPUP) Survey includes a variety of care settings. The purpose of this study is to present 10 years of US prevalence and limited demographic data (2006-2015) by care setting. METHODS: Facilities volunteer to participate in the IPUP Survey. Internal clinical teams collect data during a predetermined 24-hour period that includes pressure injury prevalence, demographics, and other pertinent clinical information. Aggregate data was analyzed for this study. RESULTS: The sample for this study was 918,621 patients in the United States; data collection spanned 2006 to 2015. The overall prevalence (OP) of PI in all facilities declined from 13.5% (2006) to 9.3% (2015). Facility-acquired prevalence (FAP) declined from 6.2% (2006) to a range of 3.1% to 3.4% (2013-2015). Acute care OP was 13.3% in 2006 and declined to a range of 8.8% to 9.3% (2012-2015). Facility-acquired prevalence in acute care declined from 6.4% (2006) to 2.9% in 2015, with 2008-2009 showing the most aggressive decline. Long-term acute care (LTAC) had the highest OP at 32.9% in 2006; it declined to 28.8% in 2015. The LTAC-FAP was 9.0% in 2006; it declined to 5.6% in 2015. Recently, the long-term care (LTC) FAP rose from 3.8% in 2013 to 5.4% in 2015. The rehabilitation facility FAP was 2.6% to 2.8% over the last 3 years. Average patient age declined in all care settings with the exception of LTAC and LTC. Braden Scale risk scores remained constant and weight increased in all care settings with the exception of LTC. CONCLUSIONS: The OP and FAP in acute care and rehabilitation have declined significantly over this 10-year period. Analysis of OP and FAP in LTC and LTACs varied without any clear-cut directional trends. General facility demographic trends indicate that mean patient age has decreased, Braden Scale scores for pressure injury risk has remained constant, and weight has increased in most care settings.VIDEO ABSTRACT available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JWOCN/A37).

Pressure Ulcer Risk in the Incontinent Patient: Analysis of Incontinence and Hospital-Acquired Pressure Ulcers From the International Pressure Ulcer Prevalence™ Survey.

PURPOSE: To measure the prevalence of incontinence in the 2013-2014 International Pressure Ulcer Prevalence (IPUP) surveys and determine the relative risk of developing a facility-acquired pressure ulcers (FAPUs) by stage and by Braden Scale score groupings. DESIGN: The IPUP survey is an observational, cross-sectional cohort database designed to determine the frequency and severity of pressure ulcers in various populations. SUBJECTS AND SETTING: The survey includes acute care (91.4%), long-term acute care (1.7%), rehabilitation patients (1.7%) and long-term care residents (5.2%). Geographic distribution included 182,832 patients in the United States, 22,282 patients in Canada, and the rest of the world, primarily in Europe and the Middle East. METHODS: We analyzed data from the 2013 and 2014 IPUP surveys to better understand the relationship between incontinence and the frequency and severity of FAPUs. The IPUP survey is an annual voluntary survey of patients who are hospitalized or who reside in long-term care facilities. Data were collected over a 24-hour period within each participating facility. Data collection included limited demographics, presence and stage of pressure ulcers, and pressure ulcer risk assessment score (Braden Scale for Pressure Sore Risk, Braden Q, Norton, Waterlow, and others). In addition, data were collected on pertinent pressure ulcer risk factors including the number of linen layers, use of a pressure redistributing surface, adherence to repositioning schedule, and whether moisture management was provided in the last 24 hours. We aggregated data by urinary, urinary catheter, fecal, fecal management system, double (urinary and fecal), and ostomy incontinence category. If patients were managed by indwelling urinary catheter or fecal management systems, they were considered incontinent in this analysis. In order to analyze ulcers likely to be affected by incontinence, we defined a subset of ulcers as Relevant Pressure Ulcers, which are ulcers that are facility-acquired, non-device-related, and located in the pelvic region. RESULTS: We analyzed 176,689 patients based on data collected between 2013 and 2014. Slightly less than half (n = 83,800; 47%) of patients did not have incontinence, and 92,889 (53%) were deemed to be incontinent. The prevalence of pressure ulcers was 4.1% for continent patients and 16.3% for incontinent patients; the prevalence of FAPUs was 1.6% and 6.0%, respectively. The relative risk for PU development in incontinent patients was higher than predicted by the Braden Scale risk score. As wound severity increased, the odds ratios for pressure ulcer development for incontinent patients versus continent patients also increased, especially in patients with fecal incontinence. CONCLUSIONS: Incontinent patients had higher Braden Scale scores and higher overall and FAPU prevalence. Incontinence was associated with an increased risk for all pressure ulcers, but especially full-thickness injuries.

Standardizing Support Surface Testing and Reporting: A National Pressure Ulcer Advisory Panel Executive Summary.

In 2001, the National Pressure Ulcer Advisory Panel's Research Committee identified the need to create uniform terminology, test methods, and reporting technical standards for support surfaces. As a result, the S3I Committee was formed and initial meetings of interested stakeholders who included clinicians, researchers, academics, manufacturers, providers, and regulators were held. The group's initial goal was to (1) establish common language to facilitate understanding by developing standardized terminology for describing and discussing support surfaces, (2) establish a suite of standardized tests of performance capable of repeatedly, reliably, and accurately reporting upon characteristics common to all support surfaces that are believed to be related to the extrinsic risk factors associated with skin breakdown, as indicated by the literature to date, and (3) identify and standardize methods to evaluate the effective life of a support surface. The purpose of this article was to summarize the current status of the effort of the Support Surface Standards Initiative (S3I) Committee to identify and standardize methods to evaluate the many characteristic factors that determine the effective life of a support surface.

Relative contributions of interface pressure, shear stress, and temperature on ischemic-induced, skin-reactive hyperemia in healthy volunteers: a repeated measures laboratory study.

Although the primary risk factors for pressure ulcer development - pressure, shear, skin temperature, moisture, and friction - have been identified for decades, the relative contribution of each to this risk remains unclear. To confirm the results of and expand upon earlier research into the relative contributions of interface pressures, shear stress, and skin temperature among 4 healthy volunteers, a study involving 6 additional healthy 40- to 75-year-old volunteers was conducted and results of the 2 studies were pooled. All 3 variables (interface pressures, shear stress, and skin temperature) were systematically and randomly varied. In the prone position, volunteers each underwent 18 test conditions representing different combinations of temperature (28˚ C, 32˚ C, 36˚ C), pressure (8.0 and 13.3 kPa), and shear (0, 6.7, and 14.0 kPa) using a computer-controlled indenter applied to the sacrum for 20 minutes exerting weights of 100 g and 200 g to induce 0.98 N and 1.96 N of shear force, respectively. Each condition was tested twice, resulting in a total of 360 trials. Magnitude of postload reactive hyperemia as an index of ischemia was measured by laser Doppler flowmetry. Fixed effects regression models were used to predict 3 different indices of reactive hyperemic magnitude. Friedman tests were performed to compare the reactive hyperemia among 3 different skin temperatures or shear stresses under the same amount of localized pressure. In all regression models, pressure and temperature were highly significant predictors of the extent of reactive hyperemia (P <0.0001 and P <0.0001, respectively); the contributions of shear stress were not statistically significant (P = 0.149). With higher temperature, reactive hyperemia increased significantly, especially at greater localized pressure and shear stress, and the difference was more profound between 32˚ C and 36˚ C than between 28˚ C and 32˚ C. These results confirm that, in laboratory settings, temperature is an important factor in tissue ischemia. Additional studies examining the relative importance of pressure, shear, and temperature and potential effects of lowering temperature on tissue ischemia in healthy volunteers and patients at risk for pressure ulcer development are warranted. Because deformation at weight-bearing areas often results in blood flow occlusion, actively lowering the temperature may reduce the severity of ischemia and lower pressure ulcer risk. In this study, shear did not appear to contribute to ischemia in the dermal tissues when assessed using laser Doppler; further work is needed to examine its effect on deeper layers, particularly with regard to nonischemic mechanisms.

A laboratory study examining the impact of linen use on low-air-loss support surface heat and water vapor transmission rates.

Layers of linens are frequently placed under patients to manage moisture and/or assist with positioning immobile patients, including persons placed on a therapeutic surface because they are at risk for developing pressure ulcers. Because skin microclimate is believed to affect pressure ulcer risk, some therapeutic surfaces are designed to manage skin temperature and humidity (microclimate management). The purpose of this study was to measure the effects of linens and underpads on a low-air-loss (LAL) surface's ability to disperse heat and evaporate moisture. Underpads and transfer sheet combinations (grouped by three common linen functions: immobility, moisture management, and immobility and moisture management) were tested using the sweating guarded hot plate method, which allows for the measurement of the evaporative capacity (g H2O/m2*hour) and the total rate of heat withdrawal (Watts/m2) associated with nine different linen configurations placed on the support surface. Total heat withdrawal and evaporative capacity of the LAL surface with a fitted sheet only was used for comparison (P <0.05) Compared with fitted sheet only, heat withdrawal was significantly reduced by five of eight combinations, and evaporative moisture reduction was significantly reduced by six of eight linen combinations (P <0.05). All combinations that included plastic-containing underpads significantly reduced the surface's ability to dissipate heat and evaporate moisture, and use of the maximum number of layers (nine) reduced heat withdrawal to the level of a static, nonLAL surface. The results of this study suggest that putting additional linens or underpads on LAL surfaces may adversely affect skin temperature and moisture, thereby reducing the pressure ulcer prevention potential of these surfaces. Additional studies to examine the effect of linens and underpads as well as microclimate management strategies on pressure ulcer risk are needed.

The effect of multiple layers of linens on surface interface pressure: results of a laboratory study.

Underpads and layers of linens are frequently placed under patients who are incontinent, have other moisture-related issues, and/or are immobile and cannot reposition independently. Many of these patients are also at risk for pressure ulcers and placed on pressure-redistribution surfaces. The purpose of this study was to measure the effects of linens and incontinence pads on interface pressure. Interface sacral pressures were measured (mm Hg) using a mannequinlike pelvic indenter that has pressure transducers integrated into the unit and is covered with a soft flesh-like elastomer. The indenter was loaded to simulate a median-weight male (80 kg/176 lb), and the testing was performed at head-of bed (HOB) angles of 0°, 30°, and 45°. Two different surfaces, a high performance low-air-loss support (LAL) surface and a standard foam support surface, were used and covered with a fitted sheet (FS) only or a combination of the FS and various incontinence pads and transfer sheets. Linen combinations typically used for relatively immobile patients (n = 4), moisture management (n = 4), and moisture management and immobility (n = 1) were tested, as was the heavy use of linens/pads (nine layers, n = 1). All combinations were tested 10 times at HOB angles of 0°, 30°, and 45°. The highest pressure observed was recorded (peak pressure). Ninety five percent (95%) confidence interval (CI) surrounding the mean of the 10 trials for each combination was calculated using the t-distribution; differences between means for all surface combinations were determined using one-way ANOVA with follow-up Fisher Hayter test. Results indicated that each incontinence pad, transfer sheet, or combination of linens significantly increased the mean peak sacral pressure when compared to a single FS on both the low-air-loss surface and the foam surface, regardless of the head-of-bed angle. The magnitude of peak sacral interface pressure increase for the LAL surface at 30° head-of-bed angle was 20% to 64% depending on the linen combination. At 30°, the foam surface showed increases 6% to 29% (P <0.0001) compared with a FS baseline. If linens were wet, peak interface sacral pressures were equivalent to or less than pressures measured on the same pads when measured dry. The presence of linens on both surface types adversely affected the pressure redistribution capabilities of the surfaces; added layers increased pressure proportionally. The effect on interface pressure from the linen layers was more pronounced on the LAL than the foam surface. The study results illustrate that significant increases in peak interface pressure occur in a laboratory setting when linen layers are added to pressure redistribution surfaces. Results also indicated wetting incontinence pads on a support surface did not significantly increase interface pressure. Although additional preclinical and clinical studies are needed to guide practice, excessive linen usage for patients on therapeutic support surfaces should be discouraged.

The relative contributions of interface pressure, shear stress, and temperature on tissue ischemia: a cross-sectional pilot study.

Tissue ischemia is thought to play a major role in the development of pressure ulcers. Pressure, shear, and temperature are acknowledged contributors, but the relative magnitude of each factor is largely unknown. A cross-sectional pilot study was conducted on the sacrums of four healthy volunteers to estimate the relative contributions of each variable by systematically varying and assessing the resulting level of ischemia in the skin tissue. Using a repeated measures design, 21 combinations of temperature (28˚C, 32˚C, and 36˚C); pressure (0 kPa, 8.0 kPa, and 13.3 kPa), corresponding to 0 mm Hg, 60 mm Hg, and 100 mm Hg; and shear stress (0 kPa, 6.7 kPa, and 14.0 kPa), corresponding to 0 mm Hg, 50 mm Hg, and 100 mm Hg (practical testing values), were tested twice, for a total of 168 trials. Using laser Doppler flowmetry, the magnitude of post-load reactive hyperemia was used as an index of ischemia. Fixed Effects and Ranks linear regression models were developed to predict three different indices of reactive hyperemic magnitude with pressure, shear stress, and temperature as the variables. Pressure and temperature were always highly significant predictors of the extent of reactive hyperemia (P <0.0001 for Perfusion Area, peak minus baseline blood flow, and Normalized Peak blood flow), and the contributions of shear stress were insignificant (P = 0.5351 for Perfusion Area, P = 0.6403 for Peak minus Baseline blood flow, and P = 0.8941 for Normalized Peak blood flow). Depending upon the model, comparison of coefficients suggested that an increase of 1.0˚C contributes as much to reactive hyperemia in the skin as 12 mm Hg to 15 mm Hg of interface pressure (coefficient ratios of temperature/pressure are 14.33 for Perfusion Area, 11.77 for Peak minus Baseline, and 12.97 for Normalized Peak, respectively). The findings also indicate that post-load metabolic repayment varied with temperature only at higher pressures, suggesting protective vasodilation was able to keep pace with mild compression. If confirmed in subsequent studies, the results suggest that managing both skin pressure and temperature may reduce the risk of ischemia.

Estimates of evaporation rates from wounds for various dressing/support surface combinations.

The management of exudate is an essential aspect of wound care. The wound bed must remain moist to promote healing, but care must be taken to remove excess fluid to avoid maceration and subsequent breakdown of the periwound site, which could serve as a possible portal to infection. Excess fluid is typically absorbed into and/or evaporates through the wound dressing or may be managed by a powered vacuum-assisted closure device. Although the moisture vapor permeability has been studied for dressings, the rate of evaporation associated with wound's immediate treatment environment, or dressing/treatment surface interface, has not been addressed to date. It is essential for caregivers to have an understanding of how these 2 interventions work together in order to provide optimal care to the wound patient. The purpose of this study was to provide estimates of evaporative withdrawal rates for various wound dressings and therapeutic support surfaces.

Air-fluidized therapy: physical properties and clinical uses.

Since the late 1960s, air-fluidized therapy (AFT) has been effectively used to treat patients with pressure ulcers, burns, and many other clinical problems. Much of the demonstrated efficacy is believed to be associated with the unique fluid environment provided by AFT that is fundamentally different from the support provided by surfaces made up of conventional solid materials. Fluid support maximizes the envelopment of the body while significantly reducing shear, friction, and pressure, and mechanical stress applied to the skin and subcutaneous tissue. Additionally, the variable temperature airflow allows the microclimate to be controlled according to needs for both therapy and patient comfort. Clinical benefits of AFT include faster and more cost-effective healing of pressure ulcers, a decreased rate of hospitalizations and emergency room visits for long-term care pressure ulcer patients, decreased mortality of patients with extensive burns and inhalation injury and rapid healing and increased comfort in burn patients. The fluid support also results in a substantial decrease in the amount of caregiver effort required for repositioning patients and increased patient comfort in patients with multiple trauma and external fixation devices or deformities that require a conforming bed, and patients with cancer and bony metastasis. This article seeks to evaluate the physical differences in AFT over other mattress types and to review the published literature for this therapy modality.

The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009.

OBJECTIVE: Suspected deep tissue injury (sDTI) was identified in 2001 and added as a staging definition by the National Pressure Ulcer Advisory Panel in 2007. Clinical data on sDTI are sparse. This article reports the overall prevalence data and describes the demographics of subjects with sDTI from the International Pressure Ulcer Prevalence survey 2006-2009. METHODS: Participating healthcare facilities performed prevalence surveys in their facility during a pre-determined 24-hour period within a pre-selected 2- to 3-day window. All generated data was incorporated into the database, even if specific data fields were absent. RESULTS: Approximately 79,000 to 92,000 patients were surveyed each year from 2006 to 2009. The overall and nosocomial pressure ulcer (PrU) prevalence decreased by approximately 1% in 2009 (P < .001), after remaining fairly constant in the years 2006-2008. The proportion of ulcers identified as sDTI has increased 3 fold, to 9% of all observed ulcers in 2009 and is more prevalent than either Stage III or IV ulcers. Over the same period, the proportion of Stage I and II ulcers have decreased, and the proportion of Stage III and IV ulcers has remained nearly constant. Patients with sDTIs are older than patients with Stage III, IV, and Unstageable ulcers. The anatomic location of sDTIs are more commonly found at the heel (41%), the sacrum (19%), or the buttocks (13%). Compared with other staged ulcers, sDTIs are significantly more prevalent at the heel (P < .001) and the ankle and foot (P < .001) and less prevalent at the sacrum and coccyx (P < .001) and at the buttocks and ischial tuberosities (P < 0.001). CONCLUSION: The survey data indicate that a decrease in overall prevalence of PrUs, as well as hospital-acquired PrUs, may have occurred in 2009. Suspected deep tissue injuries have become more commonly identified, which may be secondary to education of staging definitions.

Body mass index, weight, and pressure ulcer prevalence: an analysis of the 2006-2007 International Pressure Ulcer Prevalence Surveys.

To assess the relationships among pressure ulcer prevalence, body mass index (BMI), and weight, this report analyzed the US data from the 2006 and 2007 International Pressure Ulcer Prevalence Surveys. Findings indicated an overall reduction in pressure ulcer prevalence from 2004 and 2005 to 2006 and 2007; there was a higher prevalence of pressure ulcers in patients with low BMI and patients with both low and high weights. One in 10 patients were extremely obese.