INTRODUCTION

The past year has been like no other as clinicians across the world have battled the COVID-19 pandemic. Dermatologic manifestations of COVID-19 are being increasingly recognized,1 and the prone positioning, prolonged immobility, hemodynamic instability, and hypercoagulable state associated with COVID-19 infection are almost certainly contributing to the development of pressure injuries (PIs). Further, the pandemic has highlighted existing challenges for busy clinicians trying to stay current with the medical literature. This is especially true for the field of PIs, in which high-quality research is continuously performed around the world and results are published in a wide variety of different journals. In August 2020, the authors published a review of six important articles on PI that had been published in 2018 and 2019.2 However, the literature on PI continues to grow rapidly, and many new and important publications have appeared in just the past year. Accordingly, the authors set out to update their review.

A PubMed search using the terms pressure ulcer or pressure injury and limited to 2020 yielded more than 600 citations. For this curated update, the authors review six of these PI articles. Articles were selected by the authors based on their perceived importance. The articles should not be considered the six "best" articles from 2020, but rather represent important additions to the field in the view of the authors. Articles were selected from the English literature to represent diverse topics including PI pathophysiology, risk factors, prevention, and epidemiology. The authors did not limit the articles to original research studies but also considered insightful reviews and syntheses of data. To avoid any potential bias in article selection, the authors did not include any self-authored articles or articles published in this journal, Advances in Skin and Wound Care.

For each article, the authors first provide the reference in bold text. Next, the key findings from the article are summarized. Finally, the authors offer comments describing why the article is important or impactful for clinical practice today.

ARTICLE 1

Labeau SO, Afonso E, Benbenishty J, et al. Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study. Intensive Care Med 2021;47(2):160-9.

The goal of this study was to present a geographically diverse view on the prevalence of PIs among adult ICU patients, identify patient characteristics associated with ICU-acquired PIs, and determine the association between PIs and hospital mortality. A 1-day point prevalence study was performed on May 25, 2018, of all adults in the ICUs of 1,117 hospitals from 90 countries across six continents. Patients were then followed for up to 12 weeks for survival status and length of hospital stay. Their PI status was determined by direct observation, whereas other data were collected from medical records. The final sample consisted of 13,254 patients of whom 3,526 (26.6%, 95% confidence interval [CI], 25.9%-27.3%) had a PI.

Among patients with a PI, 36.4% had more than one. The ICU-acquired PIs were identified in 16.2% (95% CI, 15.6%-16.8%) of the sample. The ICU-acquired prevalence for PIs of stage 2 or worse was 11.0% (95% CI, 10.5%-11.5%). Prevalence rates were highest in countries with low to lower-middle economies. The majority of PIs were located on the sacral region (37.0%) followed by the heels (19.5%). Patient characteristics significantly associated with an ICU-acquired PI included lower Braden Scale score, the length of ICU stay prior to the study day, older age, male sex, underweight, admission for emergency surgery, chronic obstructive pulmonary disease, immunodeficiency, renal replacement therapy, and a more abnormal Simplified Acute Physiology Score II. Hospital mortality was 22.5%, and after adjusting for disease severity, higher PI stages were associated with greater risk of death. For stage 3 or worse PIs, the associated odds of dying were 2.31 (95% CI, 1.96-2.71) times higher compared with no PI.

Study limitations identified by the authors include the cross-sectional design that biased the sample to include more people with longer lengths of stay, uncertain generalizability, potential inconsistencies in data reporting, and lack of information on mucosal injuries. The authors conclude that PIs are common among adult ICU patients, and ICU-acquired PIs are associated with increased mortality.

Comment

As far back as 1990, a Lancet editorial highlighted that "pressure sores are not irremediable afflictions of long-stay patients but a sign of acute illness."3 It is not surprising then that PIs remain a serious but understudied condition for ICU patients. A 2018 systematic review and meta-analysis identified 22 different studies, many over 10 years old, on the incidence and prevalence of PIs in the ICU.4 Among the eight studies with 13,144 participants reporting on prevalence in this meta-analysis, the 95% CI was 16.9% to 23.8%. When limited to stage 2 or deeper PIs, the prevalence CI was 12.4% to 15.5%.

Thanks to the landmark DecubICUs study, we now have extensive new information on PIs in the ICU. Using standardized data collection protocols, PI data were obtained on a single day in 2018 for thousands of patients-and the results are not reassuring. The overall PI prevalence was 26.6%, 18% for stage 2 and higher, and nearly 61% were ICU-acquired. Although one must be exceptionally cautious in comparing prevalence rates from different studies using different data collection methodologies, it is possible to comfortably state that there have been no dramatic improvements in prevalence despite all we have learned in recent years on how to prevent PI. Possible reasons for this may include a trend toward ICUs admitting older patients with more comorbidities,5 skin failure in the setting of acute illness, more frequent use of medical devices,6 and the expanding definition of PIs to now include deep-tissue injury. It is also unclear how representative these ICUs are, and it may be they were more likely to be in academic tertiary-care referral medical centers with more complex patients.

The DecubICUs study has also highlighted how ICU patients with PIs tend to be much sicker than those without and have increased mortality. Importantly, this increased mortality persists even after adjusting for other diseases, and patients with deeper PIs were more likely to die. This association between PI stage and increased mortality has not always been seen in studies from other settings7 and suggests that, at least among ICU patients, PIs may directly contribute to the risk of dying rather than just being a marker of people who are severely ill. Possible mechanisms for this increased mortality include sepsis and a proinflammatory state induced by the PI.

Finally, the finding that PI prevalence is higher in countries with low- and middle-income economies points to another challenge for the wound healing community. How do we ensure that people in all countries, and not only those in wealthy countries that can afford the latest technology, have access to sufficient resources to help prevent PIs in ICU patients?

ARTICLE 2

Hahnel E, El Genedy M, Tomova-Simitchieva T, et al. The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: a randomized controlled parallel-group trial. Br J Dermatol 2020;183:256-64.

This randomized controlled trial was performed to determine whether the application of preventive, multilayered, soft silicone foam dressings to the sacrum and heels of ICU patients is effective in preventing PIs. The study was performed in the ICUs of a single German hospital. Eligible participants were ICU patients older than 18 years who were seen within 6 hours of ICU admission, at high or very high risk for PI development, and had an expected length of stay in the ICU of 3 days or longer. Investigators screened 7,575 ICU patients for study inclusion; 475 patients were randomized to one of the two interventions, but 53 people were excluded postrandomization, resulting in a final sample of 422 participants. Patients in the intervention group received dressings applied to both heels and the sacrum along with usual care; the control group received usual care. Dressings were changed every 3 days. The primary outcome was the cumulative incidence of stage 2 or higher PIs on the heel and sacrum. Secondary outcomes included PI incidence per 1,000 bed-days of care and cumulative incidence including stage 1 PIs. The occurrence of a PI was determined by daily skin inspections performed by members of the research team; blinding of team members was not possible.

Study participants had a mean age of 63.5 years, 65.4% were men, and had a mean body mass index of 26.5 kg/m². The average follow-up was 12.6 +/- 12.7 days, although the longest follow-up period was 130 days. Twenty-eight participants (6.6%) developed a new PI, mostly stage 2 or a deep-tissue injury. The difference between the two groups in the primary outcome was significant (P = .001) with a relative risk in the intervention group compared with the control group of 0.26 (95% CI, 0.11-0.62). This translated into needing to treat only 12.3 patients with preventive dressings to prevent one PI. Results demonstrated similar benefits for dressings in secondary outcomes; only two minor adverse events were noted in those receiving the preventive dressings.

The pragmatic design of this study evaluating effectiveness within a real-world setting was viewed as a major strength of the study. Limitations noted by the authors include potential bias from the lack of blinding and a lack of generalizability because the study was conducted at one hospital. The authors concluded that the application of preventive dressings, in addition to standard preventive care, can prevent sacral and heel PI.

Comment

Given the high prevalence of PIs in ICUs, interventions that can help prevent them are desperately needed. Multilayered silicone foam dressings placed over bony prominences are increasingly advocated as an effective intervention to prevent PI. They are believed to work by reducing friction between the outer dressing and support surface, thus reducing shear within underlying tissues; they also confer beneficial effects on the microenvironment.8 The most recent 2019 European Pressure Ulcer Advisory Panel/National Pressure Injury Advisory Panel/Pan Pacific Pressure Injury Alliance International Guideline rated the strength of evidence in support of prophylactic dressings as B1, just below the strongest level of evidence supporting an intervention.9 Now there is another high-quality level 1 study to add to this growing literature with little reason to question its internal validity. Moreover, a separate cost-effectiveness analysis of these data demonstrated that prophylactic dressings are cost-effective especially when applied over the sacrum.10 The incremental cost per sacral PI prevented was just over [Euro sign]700, or about $750.

The study is from a single hospital, and there were many exclusion criteria for study entry, which could raise questions about external validity. However, because its results are so highly consistent with other literature, and the study population includes people at highest risk for PI, these concerns are lessened. Although the use of silicone foam dressings for PI prevention in high-risk ICU patients should potentially be considered part of the "standard of care," there still are important caveats. First, we still do not know which patients and anatomic sites will benefit most from the intervention. Second, not all dressings are the same, and different products may not be equivalent at preventing PI. Third, it must be emphasized that use of prophylactic dressings does not imply that providers need not be as vigilant in other preventive practices. Finally, as most of the PIs in the study were either stage 2 or deep-tissue injuries that apparently did not progress to ulceration, it is not certain whether preventive dressings will prevent the deep stage 3 and 4 wounds of most concern.

ARTICLE 3

Jiang Q, Liu Y, Wei W, et al. The prevalence, characteristics, and related factors of pressure injury in medical staff wearing personal protective equipment against COVID-19 in China: a multicentre cross-sectional survey. Int Wound J 2020;17:1300-9.

The aim of this study was to investigate the prevalence and characteristics of medical device-related PI (MDRPI) among medical personnel using personal protective equipment (PPE) during the COVID-19 pandemic. The authors developed a survey tool that captured information on demographics, PPE use, occurrence of skin injury, and prevention and management strategies. The survey was sent out electronically to healthcare workers caring for patients with confirmed or suspected COVID-19 and completed via cellphone. Participation was voluntary. The study team determined that a sample size of 2,123 participants would be needed to effectively evaluate prevalence and the characteristics of MDRPI.

The survey was sent out on February 8, 2020, to staff at 161 hospitals spanning 28 provinces in China. A total of 4,306 surveys were successfully completed; 11.7% of respondents were doctors, and 88.3% were nurses. The average daily PPE wear time was 7.67 hours, and 34.07% of participants reported heavy sweating while wearing PPE. Approximately 21% reported using foam/hydrocolloid dressings or other personal skin-protecting agents. The prevalence of MDRPI caused by PPE was 30.03% (95% CI, 28.69%-31.41%). Among people reporting an MDRPI, 78% had more than one PI. The MDRPIs were overwhelmingly stages 1 and 2 (98.84%). The most common anatomic locations of the PIs were the nose and cheeks. In multivariate analysis, male sex (odds ratio [OR], 1.55; 95% CI, 1.12-1.99), use of level 3 PPE (OR, 1.44; 95% CI, 1.14-1.83), daily wear time greater than 4 hours (OR, 2.20; 95% CI, 1.50-3.06), and heavy sweating (OR, 43.99; 95% CI, 34.46-56.17) were all significantly associated with MDRPI.

The authors conclude that the prevalence of MDRPI is high among medical staff wearing PPE. Attempts should be made to limit daily wear time to 4 hours or less. The effect of preventive dressings under PPE requires further investigation.

Comment

The use of PPE by frontline healthcare workers during the COVID-19 pandemic has unleashed a wave of MDRPI primarily impacting the face and ears. In this article by Jiang et al, with responses from more than 4,300 physicians and nurses, more than 30% reported at least one PI. Although this number is extremely high, it is fortunate that deep-tissue injuries and stage 3 PIs were uncommon, occurring with just over 1% of the PIs. Further, response rate to the survey was not reported, and it could be that people developing a PI were more likely to provide answers.

Gefen and Ousey,11 in an important review article, highlight the mechanisms by which MDRPIs are occurring in healthcare workers including sustained distortion of facial tissues from tight-fitting masks and goggles, friction from masks during use of facial muscles such as when talking, and changes in the facial microenvironment from perspiration and other sources of moisture. An NPIAP position statement on preventing PIs from masks recommends the application of liquid skin sealants/protectants to skin surfaces that will be in contact with the mask.12 The NPIAP does not recommend the use of petroleum jelly because it is potentially flammable, but others have suggested that commercially available brands are not flammable and very effective in reducing friction. The use of a thin prophylactic dressing under a mask is very effective at preventing facial tissue deformations in patients using noninvasive ventilation masks,13 but it is uncertain whether this could increase the risk of COVID-19 infection by altering the seal. Fit testing can be performed to ensure that the seal is not compromised.

Skin care protocols incorporating a silicone border dressing cut into strips have also been described.14 Until more is known, safe practices such as those emphasized by the NPIAP include removing protective devices in a non-patient-care area for 15 minutes every 2 hours, although others have suggested longer intervals of every 4 hours.14 More information is urgently needed; frontline healthcare workers confronting the COVID-19 pandemic should not have to face the added risk of PI.

ARTICLE 4

Han D, Kang B, Kim J, et al. Prolonged stay in the emergency department is an independent risk factor for hospital acquired pressure ulcer. Int Wound J 2020;17:259-67.

The aim of this study was to determine whether a prolonged ED length of stay is an independent risk factor for hospital-acquired PI. This was a retrospective observational study using the electronic medical records from a tertiary academic hospital in South Korea. The sample included adults admitted to the hospital from the ED between April 1, 2013, and December 31, 2016, with a total sample size of 48,641. The primary outcome, the occurrence of a hospital-acquired PI during the month following admission, was evaluated via logistic regression. In addition, time to PI development was examined to take into account that the effect of the ED stay on PIs likely diminishes over time. This was accomplished with a Cox regression with time-varying coefficients. The time intervals included 1 week, 2 weeks, and 1 month following the ED stay. Models adjusted for measures of disease severity including comorbidities and laboratory results, but information on some risk factors for PIs including incontinence, smoking, and support surface use was not available.

Overall, 930 patients or 1.9% of the sample had a documented hospital-acquired PI. Compared with patients who remained in the ED for less than 6 hours, the ORs (with 95% CI) for developing a PI were 1.30 (1.05-1.60) for a stay of 12 to 24 hours and 1.80 (1.45-2.23) for stays greater than 24 hours. The Cox regression demonstrated that this increased risk is transient and affects only the first week following the ED stay. Hazard ratios in the first week were 1.42 (1.07-1.88) and 1.92 (1.44-2.57) for stays of 12 to 24 hours and greater than 24 hours, respectively. The authors conclude that prolonged ED stays are an independent risk factor for hospital-acquired PIs.

Comment

The hectic pace of care in an ED would suggest that this is not a site in which effective protocols for PI prevention can be easily implemented. Further complicating effective PI prevention are the many patients who require immobilization or are hemodynamically unstable. The extent of the problem has been demonstrated in a recent meta-analysis that identified six different studies of PI incidence in the ED. The reported incidence ranged from 0.38% to 19.1%, with a pooled estimate of incidence of 6.31%.15 Although care must be taken in interpreting these results because of the very different populations studied and methodologies used, it is possible to conclude that PIs developing in EDs are common. What is novel, though, is that previous studies have not consistently demonstrated that longer times in the ED are associated with increased risk of PI. Two well-designed studies by Baumgarten et al,16,17 a nested case-control study of 195 patients with hospital-acquired PIs on the third day of hospitalization and a prospective cohort study of 658 older adult patients with hip fracture, both failed to demonstrate this expected association. That said, we now have the new data from this study by Han et al.

Although the study includes only a single site, it is a very large sample, with 48,641 ED patients subsequently admitted to the hospital. After adjusting for measures of severity, longer stays in the ED were associated with significantly higher rates of PI development. Moreover, and again confirming expectations, much of this increased risk was during the first week of hospitalization, with less impact on PIs developing later during the hospitalization. It is reassuring when contemporary studies confirm Sir James Paget's observations from the 1870s that "the risk of bed sores in the old with fractured neck of femur is chiefly in the first week; therefore treatment with a view to preventing them should commence immediately the patient [sic] takes to bed. After the first week, the risk is not nearly so great."18

Several study limitations should be emphasized beyond the single site. The overall hospital-acquired PI rate was relatively low, at 1.9%, and it is not clear how systematic the surveillance program for detecting and recording PIs was. This suggests that some PIs may have been missed. Further, it is uncertain how PIs were staged, as there is no mention of deep-tissue injuries. Finally, nearly all of the PIs were stage 1 or 2, so we learn little about deeper injuries. Nevertheless, the message is clear. Echoing Paget, effective PI prevention19 must start as soon as patients walk in the door to the ED.

ARTICLE 5

Ledger L, Worsley P, Hope J, Schoonhoven L. Patient involvement in pressure ulcer prevention and adherence to prevention strategies: an integrative review. Int J Nurs Stud 2020;101:103449.

Patients with or at high risk of PIs are frequently required to self-manage their care. The intent of this integrative literature review was to investigate from the patient perspective those factors affecting their adherence to recommended PI care strategies with an emphasis on community settings. The study followed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) standards. Eligible articles had to focus on patients' perspectives and not those of professional staff, be empirical in nature, be published after 2000, and be written in English. Although the focus was on community settings, search criteria were expanded to all healthcare settings because of a lack of sufficient literature.

Two searches were conducted in May 2017 and again in August 2018 using 10 databases and initially resulting in 1,048 potentially eligible studies. Following exclusions, the final sample for this integrative literature review included 12 studies. All of the participants were adults with a previous or existing PI, and study sample sizes ranged from 5 to 30. Studies were generally of high methodological quality. Three themes emerged from the data related to patient adherence to recommended care. The first theme was related to lifestyle considerations and how recommended care strategies may conflict with other important aspects of their life. The second theme emphasized the need for shared decision-making with patients, who wanted to be listened to and involved in all care decisions. The final theme related to pain and discomfort arising when following various prevention strategies. Despite the evident overlap across the three themes, this review offers helpful insights into PI prevention adherence from a patient perspective and suggests strategies that can help overcome related barriers.

Comment

Effective PI care requires a team that must include knowledgeable clinicians, dedicated caregivers, and engaged patients. All too often, it seems that clinicians fail to really listen to patients and decipher what is important to them, a phenomenon that is hardly unique to PI care.20 The net result may be a frayed relationship, failure to adhere to recommendations, and resulting physical harm to the patient. The importance of listening is emphasized in the new International PI Guideline; one of its good practice statements states: "set treatment goals consistent with the value and goals of the individual, with input from the individual's informal caregivers, and develop a treatment plan that supports these values and goals."9

The authors of this study remind us that patients expect providers to understand the impact of proposed interventions on their lifestyle, recognize the pain and discomfort associated with many interventions, and involve them in shared decision-making. This is consistent with the results of the recent consumer survey done by the Guideline Governance Group in developing the International Guideline for PIs, which similarly demonstrated that health professionals should establish the personal goals and support needs of individuals with or at risk of a PI (Haessler et al, unpublished data, October 2021).

Unanswered by this study is whether and how we can communicate with, and engage, the many people at risk of PI who have cognitive impairments. Bottom line, it is critical to successful care to listen to patients and involve them in PI prevention strategies that emphasize their goals for a better quality of life. Sometimes, what may be best for the PI is not best for the patient.

ARTICLE 6

Lustig M, Wiggermann N, Gefen A. How patient migration in bed affects the sacral soft tissue loading and thereby the risk for a hospital acquired pressure injury. Int Wound J 2020;17:631-40.

A common practice in healthcare is to elevate the head of the bed (HOB) to accommodate patient clinical needs. With this elevation, the body tends to slide down in the bed, a phenomenon known as migration in bed (MIB). As a result of MIB, healthcare staff must frequently reposition and pull patients back up in the bed, inducing shearing and pressure. New bed technology has been developed to reduce MIB. This study was designed to experimentally determine whether beds with migration-reduction technology do reduce MIB when compared with beds without this technology and then use computational modeling to simulate the impact of this MIB on sacral soft tissue stresses. Ten participants were identified, five men and five women with a body mass index ranging from 24.3 to 41.8 kg/m². Measurements were conducted on two bed types, one standard and one with migration-reducing technology. Each individual was tested on each bed, twice at 45[degrees] and twice at 65[degrees] of elevation of the HOB, resulting in a total of eight measurements per participant. The MIB was measured with a motion capture system that tracked changes in the location of the trochanter. Average shear stresses at the skin and in the vicinity of the sacrum as a function of the amount of MIB were then calculated using a simulation model and a 3-dimensional anatomic model of the buttocks.

The testing found that the mean migration of the trochanter in the standard bed was 7.0 +/- 2.7 cm at 45[degrees] and 7.5 +/- 3.7 cm at 65[degrees]. Use of the special bed was associated with an approximately 3-cm reduction in the amount of MIB, a significant result. The simulation model demonstrated that increased MIB was associated with greater sacral stresses and exposure of a greater volume of soft tissue. Moreover, the stresses near the sacrum averaged 1.8 times greater than the stresses on the skin surface. The authors conclude that migration-reducing therapy is effective in reducing MIB resulting from elevating the HOB and that less MIB will lower stresses on the sacral tissue. Thus, migration-reducing therapy may be particularly effective at preventing deep-tissue injuries.

Comment

The elevation of the HOB to at least 30[degrees] is associated with a decreased incidence of aspiration and ventilator-associated pneumonia.21 However, what is good for the lungs is not necessarily good for the sacrum and buttocks. Such elevations are associated with considerable MIB, in which patients slide toward the foot of the bed.22 This sliding results in increases in friction and shear with a resulting distortion of underlying tissues. Small elevations of the HOB result in most of the shear forces being delivered to the sacral area; as the HOB is progressively elevated, maximal forces are delivered to lower areas in the buttocks. The type of bed used influences the amount of MIB.23

The article by Lustig et al now makes two important contributions. First, elevation of the HOB is associated with considerable MIB, and special beds designed to reduce this do indeed work in reducing the amount of migration. Second, using the simulation model, the reduced MIB would result in a small decrease in average shear stress both at the skin surface and in the vicinity of the sacral bone. Although this is suggestive of possible benefit, it is unclear how clinically relevant the simulated reductions in shear stress are. The ultimate clinical impact, and whether reducing MIB results in lower rates of PI development, remains unknown. Further research is clearly needed to determine whether migration-reducing beds will be a useful advance in combatting shear forces.

CONCLUSIONS

Pressure injuries remain a dynamic field of study with important articles that impact clinical care regularly appearing in the literature. Some of the articles selected for this review, such as the importance of preventive dressings in ICU patients and the need to focus on preventive strategies in the ED, may immediately impact practices. Other articles, such as those looking at MIB, suggest newer concepts and practices whose future clinical impacts are not yet known. What is clear, though, is that we are likely to continue to see important research in the coming years that will help refine and improve care for people with PIs or at risk for their development.

PRACTICE PEARLS

* Over one in four ICU patients will have a PI.

* A silicone foam dressing applied to the sacrum and heels of ICU patients is effective for PI prevention.

* Personal protective equipment to guard against COVID-19 infection is a frequent cause of MDRPI.

* Prolonged ED stays increase the risk of PI development.

* Recommendations for PI prevention and treatment must consider important lifestyle considerations through shared decision-making with patients and caregivers.

References