Jill Cox PhD, RN, APN-c, CWOCNj i l lcox@sn.rutgers.edujil l.cox@ehmchealth.org

EXPLORING PRESSURE INJURIES IN THE CRITICAL CARE

POPULATION

Describe current clinical challenges in pressure injury risk assessment in the critical care population.Describe current pressure injury risk

factors that confront the critical care population.Describe current clinical challenges in

pressure injury prevention in the critical care population.

OBJECTIVES

FLORENCE NIGHTINGALE

Circa 1955

CRITICAL CARE UNITS-PAST

"Special unit saves lives"

Circa 1980

27% of all hospital admissions involve ICU stay

2.5 times more costly than other hospital admissions

ICUs led by critical care specialists (intensivist)

CRITICAL CARE UNIT- PRESENT

HCUP, 2014

SNAPSHOT OF CRITICAL CARE PATIENTS: UNITED STATES

Mortality Risk: 10-29%• MOSF• C-V Event• Sepsis

Average LOS:3.8 days

Diagnoses:Acute Respiratory FailureAcute MIIntracranial hemorrhageC-V procedureSepticemia

Common Comorbidities:DMC-V DiseaseObesity

Patients are sicker and surviving once fatal acute illnesses!

Monitoring EquipmentPharmaceutical AgentsInvasive linesTreatment Modalities

Source: SCCMCDC

Why study pressure injuries in ICU patients?

Sickest patients in our healthcare systemHighest Prevalence RatesGround Zero for PI development among hospitalized patients.

CRITICAL CARE POPULATION

SNAPSHOT OF CRITICAL CARE PATIENTS

WITH PRESSURE INJURIES

Top ComorbiditiesDiabetes

C-V Disease

Top DiagnosesTop ICU DiagnosesRespiratory Failure

Cardiac Related EventsTrauma

Sepsis/Septic Shock

Average LOS≥ 9 days

Mortality/Severity Of Illness

APACHE II: 9.5-22(8%-40%) mortality

risk

Treatment Associated Factors

Mechanical VentilationVasopressor Agents

Immobility

Age60-73 years

Pressure Injury Characteristics

Epidemiology:5%- 45%

Highly Variable!

Most Common Stages:Stage 2

Recent studies:DTPI

Location:Sacrococcygeal

Days into the ICU Admission HAPI developed:

First Week

t

A PRESSURE ULCER TOOK DOWN SUPERMAN!!

EVERY MONTH IS ICU PRESSURE ULCER AWARENESS MONTH!

DID YOU KNOW……..

94% of patients admitted into the ICU are at risk for pressure ulcers ( as measured by the Braden Scale)

Compliance to PI Risk Assessment

Tracked compliance to PI prevention strategies

Purchased critical care beds with low air loss surfaces in 2007 and again in 2015.

Pressure Injury Prevention Awareness Campaigns

OUR JOURNEY (2006-PRESENT…….)

STILL HIGH PI RATES!

Can we truly capture PI risk in critical care patients using current risk assessment tools?What are the risk factors contributing to

PI development that need greater consideration in the critical care population?Do current prevention strategies mitigate

PI risk or could these risk factors be non-modifiable?

QUESTIONS

Risk Assessment in the Critical Care

Population

Braden Scale- United StatesJackson-Cubbin Scale: EuropeWaterlow Scale: Europe

CURRENT RISK ASSESSMENT SCALES USED IN THE ICU SETTING

Bergstrom et al (1987): 60 ICU patientsConclusions from initial study:The critical cut-off point at which the patient

could be judged to be at risk for pressure sore formation was a Braden Scale score ≤ 16.Less tendency to overpredict than Norton

scale

BRADEN SCALESEMINAL WORK IN THE ICU

Most widely used RAS in the U.S.Provides uniformity to risk assessmentStructured reminders for staffDefined risk factorsEasy to complete

ATTRIBUTES

Sensitivity: what % of patients who developed a PI were classif ied as at r isk?

Specificity: what % of al l patients who remained PI free were classif ied as not at r isk?

Predictive Value of Positive Test(PVP): How well does the scale prospectively predict who wil l develop a PI?

Predictive Value of a Negative Test : (PVN): How well does the scale prospectively predict who wil l not develop a PI?

Receiver Operating Characteristic Curve (ROC): Balance of Sensit ivity/Specificity

ELEMENTS OF PREDICTIVE VALIDITY

ICU Studies: Braden Scale

Total Braden Scale Score: Mixed in ICU StudiesLow Specificity/Low PVP = High False

Positive Rate

IS THE BRADEN SCALE PREDICTIVE IN THE CRITICALLY ILL POPULATION?

OverpredictionNeed to consider PI prevention strategies in place with assessment of RAS Predictive Validity!

PREDICTIVE VALIDITY-SUBSCALESSensory

Perception

Activity

Moisture

Mobility

Nutrition

Friction /Shear

Are we capturing true risk in this population?Are RAS better than clinical judgment?Survey of Critical Care Nurses: My clinical judgment is better than any assessment scale for risk for pressure ulcers available to me. (n = 330) 25% agreed; 45% disagreed; 30% neither agree/disagree (Cox & Schallom, 2017)

Studies are mixed(NPUAP, 2014)

Can we measure PI risk using a more efficient method?

QUESTIONS TO PONDER IN PI RISK ASSESSMENT IN CC PATIENTS

Pressure Injury Risk Factors in Critical Care: What do we know today?

Cardiovascular Disease Diabetes Mellitus

Perfusion(hypotension)

Age Length of ICU admission

Vasopressor Agents

Mechanical Ventilation

TOP 7 PRESSURE INJURY RISK FACTORS

CATEGORIES

ComorbiditiesC-V Disease

DM

Iatrogenic Factors

VasopressorsMechanical Ventilation

Demographic Variables

AgeProlonged ICU

admission

Intrinsic Factors

Hypotension

Age: #1Most frequently reported predictor.Mean age across studies:55-69: all patients60-73: PI + patients

Older, but not elderly!

Length of Stay: #2PI free: 3-14 daysPI Positive: 9-24 days

Factor of time? Proxy for overall

severity of illness?

Time to PI development:First week of ICU stay

RISK FACTORS-DEMOGRAPHIC

Diabetes MellitusPrevalence of DM on the rise!Microvascular changes:capillary damage from oxidative stress/free radicals, poor perfusionMacrovascular changes:PAD, CAD, CVA

Cardiovascular Disease

CAD risk with DM Atherosclerotic

plaques

RISK FACTORS-COMORBIDITIES

IMPAIRED TISSUE OXYGENATION ANDPERFUSION

Hemodynamic instability- a primary reason for ICU admission!

Defined: Systolic < 90 mmHg; MAP < 60-70 mmHg; or in systolic BP of 40 mmHg

Poor perfusion- circulation shunted from periphery to preserve vital organs affecting tissue tolerance

RISK FACTORS: INTRINSIC HYPOTENSION

Increase MAP to improve tissue oxygenation and perfusion

Administered in profound hypotension unresponsive to fluids- shock states

Side effects: Inadequate perfusion of the extremities, mesentery, kidneys

Empirical Evidence:Vasopressor agents predictive (no specific agents)Norepinephrine and Vasopressin Predictive

RISK FACTORS: IATROGENIC/CARE RELATED

VASOPRESSOR AGENTS

VASOPRESSIN: Second line agent for

refractory vasodilatory shock states (i.e. septic shock)

Given with another vasopressor agent

Does the addition of a second line agent create a “tipping point” that accelerates pressure injury risk?

Is it the pharmacodynamics of the vasopressors?

Is it the hypotension that necessitates the use of the agent?

Is it the overall burden of illness experienced by the critically ill patient who needs vasopressors?

Is it the perfect storm?

New vasopressor agent-Angiotensin II (Giapreza)

VASOPRESSOR AGENTSPRESSURE INJURY CONSIDERATIONS

Caveat: Can’t terminate these agents to mitigate PI risk!

Respiratory Failure: most common ICU admitting diagnosis.Indications: Spontaneous respirations cannot sustain life impaired tissue oxygenation and perfusion.

Considerations in PI Risk: ?Reflection of overall

burden of illness ? Proxy for immobility ?Related to

Shear- continuous HOB

This is a life saving modality: non-negotiable to mitigate PI risk

RISK FACTORS: IATROGENIC/CARE RELATED

MECHANICAL VENTILATION

Non-modifiable

Not included in current formal PI Risk Assessment

WHAT ARE TWO COMMON ATTRIBUTES OF THESE RISK FACTORS?

Ability to prevent some pressure injuries may be

diminished in this population.

Strong potential for unavoidable pressure injuries

exists in the critically ill population.

Despite best practice PIs do occur!!Some situations favoring an unavoidable PI: Hemodynamic instability with repositioning Significant cardiopulmonary compromise impaired tissue

oxygenation and poor tissue perfusion Shock states Initiation of l ive-saving modalities when: PI prevention strategies would be contraindicated

OR Take priority over PI prevention

All situations applicable to the Critical Care Population!

UNAVOIDABLE PRESSURE INJURIES

Unavoidable pressure injuries can only be determined if PI prevention strategies are consistentlyin use!

UNAVOIDABLE PRESSURE INJURIES

If the heart and lungs can fail, why not skin? A hypoperfusion state that leads to tissue death

that occurs simultaneously to a critical illness. Pressure-related injury concurrent with acute

illness as manifested by hemodynamic instability and/or major organ system compromise.

OR IS IT ACUTE SKIN FAILURE IN THE CRITICALLY ILL?

Problem: No clear cut diagnostic criteria to validate acute skin failure or distinguish acute skin failure from a pressure injury. More work to be done!

PRESSURE INJURY STAGES

Partial-thickness loss of skin with exposed dermis. (NPUAP,2016)

Considerations: Top down

development May be a friction

component May be related to

moisture Factors that impair

tissue tolerance

PRESSURE INJURY STAGES

Stage 2

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. NPUAP,2016)Rate: 9-12% nationally

Tissue ischemia/tissue deformationReperfusion InjuryShear injury- HOB

elevation(MV;EN)Hypoperfusion

statesHypotensionShock states

DEEP TISSUE PRESSURE INJURYRATES RISING!

PRESSURE INJURY PREVENTION PRACTICES

IN CRITICAL CAREWHAT’S THE EVIDENCE?

A change in position of the lying or seated individual performed at regular intervals with the purpose of redistributing or relieving pressure and enhancing comfort.” (NPUAP, 2014)

Reposition all individuals at risk of, or with existing pressure injuries, unless contraindicated

Strength of the Evidence= A

REPOSITIONING

REPOSITIONING: CRITICAL CARE

Can critically ill, hemodynamically unstable patients be repositioned

safely?

:REPOSITIONING HEMODYNAMICALLY

UNSTABLE PATIENTS• Study in 4 ICUs in the U.S. (Mitchell et al, 2017)(AHRQ QI)(n=4075)

• Studied frequency of inability to turn and reasons for not turning. Outcomes: 1 out of 6 deemed too unstable to be turned developed a PI after 8 hours. Clinical situations that resulted in inability to turn: hypoxia, BMI > 50, 2+ organs failing, vasopressors, hemodynamic instability, surgical procedure precluded turningConclusion: Fewer than expected clinical situations resulted in inability to turn.

• Evidence Review (Krapfl et al, 2017)

• Insufficient evidence at this time to conclude that incremental repositioning of hemodynamically unstable patients deemed to unstable to turn reduced PI rates in ICU population.

REPOSITIONING TECHNIQUE

• Photo courtesy of Tod Brindle MSN, RN ET CWOCN and Linda Currie MSN, RN, ACNS-BC, CCRN-CSC Virginia Commonwealth University Medical Center

Team approach: adequate staff to assist

• Turning Trials every 8⁰• Secure all lines• Slow incremental turns to allow

for the adjustment of the body to gravitational changes

• 15° Pause15 seconds• 30° Pause15 seconds• 45° Pause 15 seconds

• Completion of turn and nursing tasks.

• Returned to 30° position using incremental shifts, wedges, pillows.

• Hemodynamics monitored for 10 minutes to determine if measures stabilize and patient recovers.

WHAT IS THE OPTIMAL TURNING FREQUENCY FOR CRITICAL CARE

PATIENTS?• Prospective, observational study: average time to turn in the

ICU 4.85 hours (Goldhill et al, 2008)

• Prospective, observational study: mean time to repositioning for all ICU = 2 hours(+/- 30 minutes); Respiratory patients positioned more frequently in semi-Fowlers; Obese patients positioned most frequently in supine position. (Tayyib et al , 2013)

• RCT: No significant difference in PI rates when turning frequency to 4 hours vs. 2 hours in mechanically ventilated ICU patients on alternating pressure pad. Increase in adverse events noted with more frequent repositioning. (Manzano, et al 2014)

Investigate efficacy of a wireless patient monitoring system for optimizing delivery of patient turning and subsequent reduction of HAPUs

• Pragmatic, open-label, two-arm, prospective, RCT in two ICUs

• 1,226 patients (671 treatment & 555 control).

Design

Findings• 43% increase in q 2-hour

repositioning compliance• HAPU rates: Treatment = 0.7%

Control = 2.7%

A decreased PI rate of 73% (OR=0.27, 95% CI [0.10, 0.75], p=0.01) (Pickham et al, 2018).

EVALUATING OPTIMAL PATIENT-TURNING PROCEDURES FOR

REDUCING PRESSURE INJURIES

Purpose

SUPPORT SURFACES?

• RCT: No significant difference in PU rates in ICU patients on 2 different types of viscoelastic foam. (Ozyurek et al,2015)

• Prospective Observational: Lower incidence of PU in critically ill patients on LAL support surfaces with microclimate management as compared to integrated power air redistribution beds (Black et al,2012)

• Quasi-experimental: Alternating pressure mattresses were more effective than alternating pressure air overlays in preventing PU in mechanically ventilated ICU patients.(Manzano et al, 2013)

• Pilot RCT: Lower PU rates in ICU patients placed on an active alternating pressure surface versus a manually inflatable static low pressure mattress. (Melbrain, 2010)

Turning/Positioning Devices

PI RatesTime/Staff

UtilizationStaff Compliance Improved turning

anglesPowers, 2016Hal l e t a l , 2016

Conformational Positioners

Buttock PIs Patient comfort ease of

positioning obese pts.

Brennan et a l , 2014

DO ASSISTIVE DEVICES REDUCE PRESSURE INJURIES IN THE

CRITICALLY ILL?

Continuous Pressure Mapping

(Beherndt et al, 2014)

Real time visual feedback regarding body positioningPI rates

Non-invasive Perfusion Enhancement System

(Bharucha et al, 2018)Goal: avoid prolonged

vascular compression to the sacrum to improve tissue

perfusion

Sacral PI as compared to alternating pressure surface

DO ASSISTIVE DEVICES REDUCE PRESSURE INJURIES?

OTHER CLINICAL CONSIDERATIONS IN REPOSITIONING

Increase Nurses’ Knowledge of Proper

TechniquesPresence of WOC

Nurse (Anderson et al, 2015)

Staff Education(Tayib et al, 2016)

Human Resource Considerations

Turn Teams (2 trained PCAs) (Still et al, 2013)

RN to verbally cue staff (Harmon et al 2016)

HOB elevation: a competing strategy?HOB elevation > 30 ⁰ No increase in PIs

(Schallom et al 2015, Grap et al , 2018)

More research needed to determine optimal turning frequencies, positioning techniques and support surfaces.Do progressive mobility programs

decrease PI occurrence in the ICU population?

There will always be critically ill patients that are too unstable to be turned- Document it!

REPOSITIONING-POINTS TO PONDER

Strengthening evidence to support this modality in ICU patients.Implementation Considerations:Strict criteria needed to determine eligible

patients to decrease overuse, misuse and associated costs.Standardized Protocols for assessment

parameters, dressing change intervals, discontinuing dressings.

More rigorous studies needed to fully understand the role of prophylactic dressings in PI reduction in this population.

PRESSURE INJURY PREVENTION IN THE ICU

PROPHYLACTIC DRESSINGS

Due to insufficient evidence to support of refute the use of specific additional nutrit ional interventions in critical care patients , specif ic addit ional nutr i t ion interventions are not recommended for routine use in the populat ion .(NPUAP, 2014 Strength of evidence = C)

There is currently no clear evidence of a benefit associated with nutrit ional interventions for either the prevention or treatment of pressure ulcers. Further tr ials of high methodological qual i ty are necessary.Cochrane Review, 2014

Difficult to measure nutritional status in CC patients

WHY? Critical illness alters common nutritional markers inaccurate diagnosis of malnutrition. Fluid shifts erroneously

influence body weight

Markers associated with inflammation, also associated with nutrition

NUTRITIONAL CONSIDERATIONS

UNDERSTUDIED thus UNDERAPPRECIATED!

Early feedings ideally within the first 24-48 hours after admission.

Preferred route for feeding= enteral route (lower infection rates)

Use of a feeding algorithm

NUTRITIONAL GUIDELINESICU

A.S.P.E.N. / SCCM GUIDELINES-2016

Legal Implications

Regulatory/Financial Implications

Quality Indicators

Challenges in Practice Today

Present on Admission Indicator

The Hospital-Acquired Condition (HAC) Reduction Program: pay-for-performance program

Mandatory State Patient Safety Reporting Requirements

N.J. “Stage III or IV pressure ulcers acquired after admission… to a health care facility.”

What about PIs that occur or worsen for which acute care clinicians believe they have little external control and cannot mitigate pressure injury development?

Financial/Regulatory

QUALITY

The National Database of Nursing Quality Indicators® (NDNQI®)Hospital acquired pressure injuries are nurse sensitive quality indicators, linking PI occurrence to the quality of care delivered by nurses.

Is PI development a Nurse Sensitive Indicator or Patient Sensitive Indicator?

Are acquired PIs only a reflection of nursing care?

Potentially inflates the reported PI rate artificially, coupled with possible negative connotations regarding the nursing care delivered.

Currently even PIs which may have been unavoidable are counted in NDNQI reporting

PROBLEM

LEGAL IMPLICATIONS/PUBLIC PERCEPTION

Over 17,000 lawsuits filed related to pressure injuries annually, second only to wrongful death, and more common than patient falls.37

What about nurses and other caregivers who find themselves involved in litigation over HAPIs that were not the result of suboptimal care?

CONCLUSIONS

PI risk in the ICU population is multifactorial and complex!

Some PIs cannot be prevented in the ICU population!

Evidence base surrounding many PI prevention strategies is weak!

WHAT WE KNOW

Improve Pressure Injury Risk Quantification in the ICU population.

Substantiate the label of the “Unavoidable Pressure Injury” in the

acute care setting

Continue to improve our evidence base surrounding PI risk factors and

PI prevention

WHAT WE STILL NEED TO DO

LOOKING TOWARDS THE FUTURE:THE ICU IN 2050

Halpern et al, 2018

THANK YOU!QUESTIONS?

1 . So c ie t y f o r C r i t i c a l Ca r e Me d i c i n e . C r i t i c a l c a r e s t a t i s t i cs . h t t p : / /www. s c cm.o rg /Commun ica t i on s /Pag es /C r i t i c a lCa reS ta t s .as px

2 . Ba r r e t t ML , Sm i t h MW , E l i xh a u s e r A , Ho n ig ma n L S , P in e s J M. U t i l i za t i o n o f I n te n s i ve Ca r e Se r v i c e s , 2 0 1 1 . He a l t h c a re Co s t a n d U l t i za t i o n P r o j e c t . 2 0 1 4

h t t p : / / hcu p-u s .ah rq .g o v / re por t s / s ta tb r i e f s / sb 1 85-Ho sp i t a l - I n ten s i ve -Ca re -Un i t s -2 0 11 . j s p 3 . Na t i o n a l P r e s s ure U l c e r Ad v i s o r y Pa n e l , Eu r o p e a n P r e s s ure U l c e r Ad v i s o r y Pa n e l a n d

Pa n Pa c i f i c P r e s s u re I n j u r y A l l i a n c e . P r e ve n t i o n a n d T r e a tmen t o f P r e s s ure U l c e r s : C l i n i c a l P r a c t i c e G u id e l i n e . Em i l y Ha e s le r ( Ed ) . Ca m b r i dg e Me d ia : O s b orn e Pa r k , W e s te rn Au s t ra l i a ; 2 0 1 4

4 . Be r g s t rom, N , B r a d e n , B , L a g u zza , A , Ho lm a n , V . T h e B r a d e n s c a le f o r p r e d i c t i n g p r e s s u re s o r e r i s k . Nu r s Re s , 1 9 8 7 ; 3 6 ( 4 ) : 2 0 5 - 2 10 .

5 . Be r g s t rom, N , De m u th , B r a d e n , B : A c l i n i c a l t r i a l o f t h e B r a d e n Sc a le f o r p r e d i c t i ng p r e s su re s o r e r i s k . Nu r s i n g C l i n i c s o f No r t h Am e r i c a ; 1 9 8 7 ; 2 2 ( 2 ) ; 4 1 7 -4 2 8 .

6 . A ld e r d e n , J , Cu m m in s , M. Pe p p e r , G , e t a l . M id r a n g e B r a d e n s u b s c a le s c o r e s a r e a s s o c ia te d w i t h i n c r e a se d r i s k f o r p r e s s u re i n j u r y d e ve lo p me nt c r i t i c a l c a r e p a t i e n t s . JW OCN, 2 0 1 7 ; 4 (5 ) : 42 0-4 28 .

7 . Hyu n , S , Ve r m i l l i o n , B e t a l . P r e d i c t i ve Va l i d i t y o f t h e B r a d e n Sc a le f o r p a t i e n t s i n i n t e n s i ve c a r e u n i t s Am e r i ca n J o u r n a l o f C r i t i c a l Ca r e 2 2 ( 6 )4 ;51 4-5 20 .

8 . Co x , J . P r e d i c t i ve p o we r o f t h e B r a d e n Sc a le f o r p r e s s u re s o r e r i s k i n a d u l t c r i t i c a l c a r e p a t i e n t s . JW OCN, 2 0 1 2 ; 3 9 ( 6 ) : 6 1 3 - 6 21 .

9 . T e s c he r , A , B r a n d o , A e t a l . A l l a t r i s k p a t i e n t s a r e n o t c r e a ted e q u a l . An a l ys i s o f B r a d e n P r e s s ure U l c e r R i s k Sc o r e s t o I d e n t i f y Sp e c i f i c R i s k s . JW OCN, 2 0 1 2 ; 3 9 ( 3 ) ; 2 8 2 -2 9 1 .

1 0 . G a r c i a -Fern a nd ez , P , Ag r ed a , J , Ro d r i q ue z T o r re s , M. R i s k a s s e s sme nt s c a le s f o r p r e s su re u l c e r s i n i n t e n s i ve c a r e u n i t s : a s ys t emat i c r e v i e w w i t h m e ta -an a l ys i s . Eu r o p e an W o un d Ma n a g e ment As s o c ia t i o n , 2 0 1 3 ; 1 3 ( 2 ) , 7 - 1 3 .

REFERENCES

11. Cox, J , & Schal lom, M. Pressure in jur ies in cr i t ica l care: a survey of cr i t ica l care nurses . Cr i t ica l Care Nurse. 2017; 37(5) 46-56.

12. Tayyib, N, Coyer, F, Lewis P, Saudi Arabian adul t in tens ive care un i t pressure u lcer inc idence and r isk factors : a prospect ive cohor t s tudy. In t Wound J 2016 Oct . , 13(5) :912-919.

13. Bly, D, Schal lom, M. Sona, C, K l inkenberg, D. A model o f pressure, oxygenat ion , and per fus ion r isk factors for pressure u lcers in the in tens ive care un i t . Am J Cr i t Care 2016; 25(2) :156-164.

14. Cox, J , Roche, S. Vasopressors and development o f pressure u lcers in adul t c r i t ica l care pat ien ts . Am J Cr i t Care 2015; 24(6) : 501-510.

15. Campin i l i , T, Conceicao de Gouveia santos , V, St razz ie r i -Pu l ido , K, Thomaz, P, Noguer ia , P. Inc idence of pressure u lcers in card iopulmonary in tens ive carer uni t pat ien ts . Rev Esc Enferm USP 2015; 49: 7-13.

16. Aposto lopoulou, E, Tseleb is , A, Terz is , K, Kamar inou, E, Lambropoulous , I , Ka l l iakman is , A. Pressure u lcer inc idence and r isk factors in vent i la ted in tens ive care pat ien ts . Heal th Sc ience Journal , 2014; 8(3) : 333-342.

17. Nassaj i , M, Askar i , Z , Ghorban i , R. Cigare t te smokikng and r isk o f pressure u lcers in adul t in tens ive care un i t pat ien ts . In t J o f Nurs Prac, 2014; 20: 418-423.

18. Ef te l i , E. Gunes, U. A prospect ive , descr ip t i ve s tudy of r isk factors re la ted to pressure u lcer development among pat ients in in tens ive care un i ts . Ostomy Wound Management 2013; 59(7) : 22-27 .

19. O’Br ien , D, Shanks , A, Ta lsma, A, Brenner, P, Ramachandran S. In t raopera t ive r isk factors assoc ia ted wi th postopera t ive pressure u lcers in cr i t ica l l y i l l pat ien ts : a re t rospect ive observa t ional s tudy. Cr i t Care Med: 2013; 42(1) 40-47.

20. Tschannen, D. Bates, O Talsma, A, Guo, Y. Pat ient -spec i f i c

REFERENCES

2 0 . T s c h an n en , D . Ba t e s , O T a l s ma, A , G u o , Y . Pa t i e n t - spe c i f i c a n d s u r g i ca l c h a r ac te r i s t i cs i n t h e d e ve lo p m e nt o f p r e s su re u l c e r s . Am J C r i t Ca r e 2 0 1 2 ; 2 1 ( 2 ) 1 1 6 - 1 2 4 .

2 1 . Se r r a , R , Ca r o le o , S . Bu f f o n e , G , L u g a ra , M Mo l i n a r i , V , T r o pe a , F , Am a n te a , B , d e F r a n c i s c i s , S . L o w s e r u m a lb u m in l e ve l a s a n i n d e p e n d e n t r i s k f a c to r f o r t h e o n s e t o f p r e s su re u l c e r s i n i n t e n s i ve c a r e u n i t p a t i e n t s . I n t W o un d J 2 0 1 2 ;1 1 (5 ) : 5 5 0 - 5 5 3 .

2 2 . W i l c zwe s k i , P , G r imm, D , G ia n ak i s , A , G i l l , B , Sa r ve r , W , Mc Ne t t , M. R i s k f a c to rs a s s o c ia te d w i t h p r e s s ure u l c e r d e ve lo p m ent i n c r i t i c a l l y i l l t r a umat i c s p in a l c o r d i n j u r y p a t i e n t s . J T r a uma Nu r s 2 0 1 2 ; 1 9 ( 1 ) : 5 - 1 0 .

2 3 . C r e m as co , M, W e nze l , F , Za n e i , S . W h i t ak e r , I . P r e s s ure u l c e r s i n t h e i n t e n s i ve c a r e u n i t : t h e r e l a t i o nsh ip b e t we e n n u r s i n g wo r k l o a d , i l l n e s s s e ve r i t y , a n d p r e s su re u l c e r r i s k .

2 4 . Co x , J . P r e d i c to r s o f p r e s su re u l c e r s i n a d u l t c r i t i c a l c a r e p a t i e n t s . Am J C r i t Ca r e 2 0 1 1 ; 2 0 ( 5 ) : 3 6 4 - 3 74 .

2 5 . Ma n za n o , F . Na va r r o , M, Ro ld a n , D Mo r a l , M. L e yva , I , G u e r re ro , Ca . Sa n c h e z , M, Co lm e n e ro , M, Fe r n a n de z-Mo nd e j a r . P r e s s ure u l c e r i n c i d e n c e a n d r i s k f a c to rs i n ve n t i l a t e d i n t e n s i ve c a r e p a t i e n t s . J C r i t Ca r e , 2 0 1 0 Se p ; 2 5 ( 3 ) :4 69 -76 .

2 6 . S lo w i k o ws k i , G , Fu n k , M. Fa c t o rs a s s o c ia te d w i t h p r e s su re u l c e r s i n p a t i e n t s i n a s u r g i c a l i n t e n s i ve c a r e u n i t . J W ou nd O s tomy Co n t Nu r s 2 0 1 0 3 7 ( 6 ) ; 6 1 9 - 6 26 .

2 7 . Ka i t a n i , T , T o k u nag a , K Ma t s u i , N , Sa n a d a , H . R i s k f a c to rs r e l a te d t o t h e d e ve lo p me nt o f p r e s su re u l c e r s i n t h e c r i t i c a l c a r e s e t t i ng . J C l i n Nu r s , 1 9 : 4 1 4 - 4 21 .

2 8 . A ld e r d e n , J , Ro n d in e l l i , J . R i s k f a c to rs f o r p r e s s u re i n j u r i e s a m o n g c r i t i c a l c a r e p a t i e n t s : a s ys t e mat i c r e v i e w. I n t e rn a t i o na l J o u r na l o f Nu r s i n g S t u d ie s ; 2 0 1 7 ; 7 1 ; 9 7 -1 1 4 .

2 9 . Ed s b e rg , L E , L a n g emo, Ba h a r e s ta n i , MM, Po s t h au er , ME , G o ld b e rg , M. Un a vo id a b le p r e s su re i n j u r y : s t a te o f t h e s c i e n c e a n d c o n s e n sus o u t c ome. J W ou nd , O s tomy Co n t i n e n ce Nu r s e , 2 0 1 4 ; 4 1 : 3 1 3 - 3 3 4

REFERENCES

30. Cox, J . Pressure in jury r isk factors in adul t c r i t ica l care pat ien ts : a review of the l i teratu re . Ostomy/Wound Management ; 2017; 63(11)30-43.

31. Mars i , J , Ze in-El -D ine, S, e t a l . Predic to rs o f pressure in jur ies in a cr i t ica l care un i t in Lebanon. J Wound, Ostomy, Cont inent Nurs 2018; 45(2) : 131-136.

32. Cox, Roche, S, Murphy, V. Pressure in jury r isk factors in cr i t ica l care pat ients : A descr ip t i ve analys is . Advances in Sk in and Wound Care. 2018; 31; 328-334.

33. Mi tchel l , M et a l , Do no turn in the ICU set t ing W CET Journal ; 2017; 37(2) ;26-31

34. Krapf l L , Langin J, e t a l . Does incrementa l pos i t ion ing (weight sh i f ts ) reduce pressure in jur ies in cr i t ica l care pat ien ts . JW OCN 2017;44(4) ; 319-323

35. Br ind le , C, Malho t ra , R, O’Rourke , S, e t a l . Turn ing and repos i t ion ing the thehemodynamica l l y unstab le pat ient in the ICU. JW OCN; 2013; 40(3) , 254-267

36. Goldh i l l , D, Badacsonyi A. e t a l . A prospec t ive observa t iona l s tudy of ICU pat ien t pos i t ion and f requency of turn ing . Anaesthes ia ; 2008; 63; 509-515

37. Tayyib, N, Lewis , P, Coyer, F. A prospec t ive observat ional s tudy of pat ient pos i t ion ing in a Saudi in tens ive care un i t ; 2013; Middle East J , 7(1) , 26-33.

38. Manzano, F, Colmenero , M, Perez-Perez, A. e t a l . Compar ison of two repos i t ion ing schedules for the prevent ion of pressure u lcers in pat ien ts on mechan ica l vent i la t ion wi th a l ternat ing pressure a i r sur faces . In t Care Med, 2014; 40: 1679-1687.

39. Ozyurek, , P Yavuz , M. Prevent ion of pressure u lcers in the in tens ive care un i t : a randomized t r ia l o f 2 v iscoelast ic foam suppor t sur faces. Cl in ica l Nurse Specia l is t , 2015; Ju ly/Aug, 210-217.

REFERENCES

4 0 . B la c k , J , Be r k e , C , U r ze n d o ws k i , G . I n f l ue nc e o f l o w a i r l o s s m a t t res s ve r s u s a p o we r e d a i r p r e s s u re r e d i s t r i b u t i o n m a t t re ss . JW OCN; 2 0 1 2 ; 3 9 ( 3 ) ; 2 6 7 -27 3 .

4 1 . Ma n za n o , F , Pe r e z , A , Co lm e n e ro , M e t a l . Co m p a r i s o n o f a l t e r na t i n g p r e s s ure m a t t res se s a n d o ve r l a ys f o r p r e ve n t i o n o f p r e s su re u l c e r s i n ve n t i l a t ed i n t e n s i ve c a r e p a t i e n t s :a q u a s i -e xp e r im en ta l s t u d y . J Ad v Nu r s ; 2 0 1 3 ; 2 0 9 9 - 2 10 6 .

4 2 . Ma lb r a i n , M, He n d r i k s , B e t a l . A p i l o t o f r a n d omizs e d c o n t ro l l e d t r i a l c o m p ar i n g r e a c t i ve a i r a n d a c t i ve a l t e r na t i ng p r e s s u re m a t t re sse s i n t h e p r e ve n t i o n a n d t r e a tme n t o f p r e s su re u l c e r s a m o n g m e d i c a l I CU p a t i e n t s . J T i s s V ia b i l i t y ; 2 0 1 0 ; 1 9 ; 7 - 1 5 .

4 3 . Ha l l , K & C la r k , R , A p r o s pe c t i ve , d e s c r i p t i ve q u a l i t y im p r o veme nt s t u d y t o i n ve s t i g a te t h e im p a c t o f a t u r n a n d p o s i t i o n d e v i c e o n t h e i n c i d e n c e o f h o s p i t a l a c q u i re d s a c r a l p r e s su re u l c e r s a n d n u r s i n g s t a f f t im e n e e d e d f o r r e p o s i t i o n i n g p a t i e n t s . OW M; 2 0 1 6 ; 6 2 ( 1 1 ) , 4 0 -44 .

4 4 . Po we r s , J T wo m e t ho ds f o r t u r n i ng a n d p o s i t i o n i n g a n d t h e e f f e c t o n p r e s s u re u l c e r d e ve lo p m ent JW OCN: 2 0 1 6 , 4 3 ( 1 ) 4 6 - 5 0 .

4 5 . B r e n n a n , M. L a c o n t i , D , G i l c h r i s t , R . Us in g c o n f o rma t i on p o s i t i o n i n g t o r e d u ce h o s p i t a l a c q u i re d p r e s su re u l c e r s . J Nu r s Ca r e Q u a l ; 2 0 1 4 ; 2 9 (2 )1 82-1 8 7 .

4 6 . Be h e r n d t , R , G h a zn a v i , A e t a l . Co n t i n u o u s Be d s id e p r e s su re m a p p ing a n d r a t es o f h o s p i t a l - a ss oc ia ted p r e s s u re u l c e r s i n a m e d i c a l i n t e n s i ve c a r e u n i t . Am J C r i t Ca r e ; 2 0 1 4 ; 2 3 , 1 2 7 - 1 33

4 7 . P i c k h a m, D , Be r te , N , e t a l . E f f ec t o f we a r a b le p a t i e n t s e n s o r o n c a r e d e l i ve r y f o r p r e ve n t i ng p r e s su re i n j u r i e s i n a c u t e l y i l l a d u l t s : a p r a g mat i c r a n d omize d c l i n i c a l t r i a l . I n t J Nu r sS t u d ; 2 0 1 8 ; 4 2 ( 3 ) ; 2 1 7 - 2 25

4 8 . An d e r s on , M, G u t h r i e , P e t a l . Un i ve r s a l p r e s su re u l c e r p r e ve n t i o n b u n d le w i t h W OC n u r s e s u p p o r t . JW OCN;2 01 5 ; 4 2 ( 3 ) 2 1 7 - 2 25

4 9 . T a yy ib , N , Co ye r , F , L e w is , P . Re g i s te red n u r s e s a t t i t u de s t o wa r d p r e ve n t i o n s t ra teg ie s a n d p e r c e i ve d f a c i l i t a to r s a n d b a r r i e r s t o e v i d e n c e im p le m en ta t i o n . JW OCN;2 01 6 ; 4 3 ( 4 )3 69 -37 4

REFERENCES

5 0 . S t i l l , M, C r o s s , L , Du n la p , M. e t a l . T h e t u rn t e a m: a n o ve l s t r a teg y f o r r e d u c ing p r e s su re u l c e r s i n a s u r g i ca l i n t e n s i ve c a r e u n i t . J Am Co l l Su r g , 2 0 1 3 ; 3 7 3 - 3 79

5 1 . Ha r m on , L , G r ob be l , C l Pa l l e s c h i , M. Re d u c in g p r e s su re i n j u r y i n c i d e n c e u s in g a t u r n t e a m a s s ig nme nt . JW OCN; 2 0 1 6 ; 4 3 ( 5 ) , 4 7 7 - 4 8 2

5 2 . Sc h a l l o m , M, Dyk e m an, B e t a l . He a d o f b e d e l e va t i o n a n d e a r l y o u t c ome s o f g a s t r i c r e f l u x , a s p i r a t i o n , a n d p r e s su re u l c e r s : a f e as ib i l i t y s t u d y . Am J C r i t Ca r e ; 2 0 1 5 ; 2 4 ( 1 ) ; 5 7 - 6 5

5 3 . G r a p , MJ , Mu n r o , C , Sc h u b e r t e t a l . L a c k o f a s s o c ia t i o n o f h i g h b a c k re s t w i t h s a c r a l t i s s u e c h a n g e s i n a d u l t s r e c e i v i n g m e c h a n i c a l ve n t i l a t i o n . Am e r i c an J o u r n a l o f C r i t i c a l Ca r e 2 0 1 8 ; 2 7 ( 2 ) 1 0 4 - 1 13 .

5 4 . Sa n t a mar i a ,N , G e r d t z , M, Sa g e , S , Mc Ca n n , J , F r e e m an, A , Va s s i l i o u , e t a l . A r a n d omize d c o n t ro l t r i a l o f t h e e f f e c t i ve n e ss o f s o f t s i l i c o n e m u l t i - l aye re d f o am d r e s s ing s i n t h e p r e ve n t i o n o f s a c r a l a n d h e e l p r e s su re u l c e r s i n t r a uma a n d c r i t i c a l l y i l l p a t i e n t s : t h e b o r d e r t r i a l . I n t . W o un d J 2 0 1 5 , J u n ; 1 2 (3 ) :30 2-8 .

5 5 . C la r k M, B la c k J , A l ve s P , B r i n d le C , Ca l l E , De a le y C , Sa n t a mar i a N . Sys t e m at i c r e v i e w o f t h e u s e o f p r o p h y la c t i c d r e s s ing s i n t h e p r e ve n t i o n o f p r e s su re u l c e r s . I n t W o un d J . 2 0 1 4 O c t ; 1 1 ( 5 ) : 46 0-71 .

5 6 . Pa d u la , W . E f f e c t i ve n ess a n d Va lu e o f P r o p h y la c t i c 5 -L a ye r Fo a m Sa c r a l D r e s s in g s t o P r e ve n t Ho s p i t a l -Acqu i re d P r e s s ure I n j u r i e s i n Ac u t e Ca r e Ho s p i t a l s An O b s e rva t i o n a l Co h o r t S t u d y , JW OCN, 2 0 1 7 ; 4 4 ( 5 ) ; 4 1 3 - 4 19 .

5 7 . T a y lo r , B , Mc C la ve , S , Ma r t i n a le R e t a l . G u id e l i n e s f o r t h e p r o v i s i o n a n d a s s e s sme nt o f n u t r i t i o n s u p p o r t t h e r ap y i n t h e a d u l t c r i t i ca l l y i l l p a t i e n t : So c ie t y o f C r i t i c a l Ca r e Me d i c i n e a n d Am e r i ca n So c ie t y f o r Pa r e n te ra l a n d En t e ra l Nu t r i t i o n . C r i t Ca r e Me d ; 2 0 1 6 ; 4 4 ( 2 ) ; 3 9 0 - 4 3 8 .

5 8 . Co x J . & Ra s m u s se n , L . En t e ra l n u t r i t i on i n t h e p r e ve n t i on a n d t r ea tme n t o f p r e s su re u l c e r s i n c r i t i ca l c a r e p a t i e n t s . C r i t i c a l Ca r e Nu r s e ; 2 0 1 4 ; 3 4 ( 6 ) : 1 5 -2 8 .

5 9 . B la c k , J , B r i n d le , C , Ho n a k er , J . D i f f e re n t i a l d i a g n o s i s o f s u s p e c ted d e e p t i s s u e i n j u r y . I n tW ou n d J 2 0 1 5 ; Ep u b 2 0 1 5 d o i ; 1 0 .11 1 / iw j . 1 24 7 1

REFERENCES

60. Oomens, CWJ, Bader, D, Loerakker, S, Baai jens, F. Pressure induced deep t issue

in jury exp la ined. 2014 Ann Biomedical Engineer ing, February 2015; 43(2): 297-305.

61. Ki rk land-Kyhn, H, Te leten, O, Wi lson, M. A re t rospect ive descr ipt ive comparat ive s tudy to ident i fy pat ient var iables that contr ibute to the development o f deep t issue in jury among pat ients in in tensive care un i ts . Ostomy/Wound Management 2017; 63(2)42-47.

62. Centers for Medicare and Medicaid Fact Sheet : Never events. Accessed October 29, 2016 at : h t tps: / /downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd073108.pdf

63. Montalvo, I . , (September 30, 2007) "The Nat ional Database of Nurs ing Qual i ty Ind icatorsTM(NDNQI®)" OJIN: The Onl ine Journal o f Issues in Nurs ing. Vol . 12 No. 3 , Manuscr ipt 2 . h t tp: / /www.nurs ingwor ld.org/MainMenuCategor ies/ANAMarketplace/ANAPeriodicals /OJIN/TableofContents/Volume122007/No3Sept07/Nurs ingQual i tyIndicators.html

64. Agency for Heal thcare Research and Qual i ty. Prevent ing pressure u lcers in hospi ta ls : a too lk i t for improving qual i ty o f care. Agency for Heal thcare Research and Qual i ty. Apr i l 2011. Agency for Heal thcare Research and Qual i ty, Rockvi l le, MD. ht tp: / /www.ahrq.gov/professionals/sys tems/ long-term-care/resources/pressure-ulcers/pressureulcertoo lk i t /putool3.html

Nei l A. Halpern,Diana C. Anderson, Jozef KeseciogluICU des ign in 2050: looking in to the crys tal ba l l ! In tensive Care Med (2017) 43:690–692

REFERENCES