1. Ayello, Elizabeth A. PhD, MS, RN, CWON, FAAN
  2. Sibbald, R. Gary MD, MEd, FRCPC, FAAD, JM

Article Content

Because pressure injuries (PIs) continue to be a healthcare concern worldwide, this issue of Advances in Skin & Wound Care marks the fifth annual PI issue. These articles from authors around the world add to our knowledge of PI risk factors, prevention, management strategies, and end-of-life wound terminology.


Pressure injury prevention is a more desirable outcome than having to treat a PI. This month's continuing education article by Barch and colleagues explores a comparison of PI factors across US inpatient post acute care settings. New and worsening PIs were more common in long-term care facilities (3.07%) than in inpatient rehabilitation settings (1.5%) or skilled nursing facilities (1.23%). The researchers identified seven risk factors: limited bed mobility, incontinence (stool, urine, or both), low body mass index, diabetes with peripheral vascular/arterial disease, and advanced age (90 years and older).


Improving integrated care can help prevent PIs. Dr Stefanescu and her interdisciplinary team report their quality improvement project in a US 60-bed level IV neonatal ICU to address the problem of electroencephalogram (EEG) electrode-related PIs. Implementation of a daily bedside skin assessment tool, interdisciplinary bedside rounds, and flexible hydrogel EEG electrodes resulted in zero EEG electrode-related PIs.


Dr Vocci and colleagues compared the Glamorgan and Braden Q Scale scores of 83 patients admitted to a Brazilian pediatric ICU between February and July 2020. They found similar performance between the scales, validating the Glamorgan Scale. If you manage pediatric intensive care patients, check out both PI risk assessment scales and consider how they may fit your patient and institutional needs.


Holster implemented a new hospital-acquired PI prevention and management protocol using long-wave infrared thermography for all patients admitted to her facility in conjunction with PI prevention and treatment bundles developed by the skin care team. This resulted in an initial complete elimination of hospital-acquired PIs. Bundled care has been successful in decreasing PIs in several studies, including in the New Jersey Hospital program, in which Dr Ayello was involved.1,2


In a systematic review, Baron et al report on the accuracy of thermographic imaging in the early detection of PI. This is an evolving science; increased temperature may relate to deep/surrounding infection or inflammation and local ischemia may lead to a decreased temperature. This is why the STONEES mnemonic has seven potential clinical signs for deep/surrounding infection, with any three required to treat the infection. As a clinical sign, increased temperature is eight times more likely to be associated with infection but still requires two other factors for systemic treatment.3


Dr Okuyama and colleagues in Brazil performed a scoping review of topical natural products applied in the care of patients with PI. Although their search identified 1,268 records in English and Portuguese, only six studies met their inclusion criteria. They found that natural products have a healing effect on PIs, but more rigorous randomized controlled trials are needed. Topical therapies penetrate only a few millimeters into the surface of a PI, and deep inflammation often requires systemic medication along with the treatment of the cause.


As the COVID-19 pandemic endures, the relationship between COVID and PIs continues to be explored. The article by Ms Savage and colleagues reports skin changes seen in patients with COVID-19, describing the tissue type, wound margin, and periwound condition. This may represent an angiosomal effect with relative ischemia linked to a potential etiologic effect of the distal PI. Also, published ahead of print is a systematic review of COVID-19 and hospital-acquired PI by a Canadian team led by Ms Bourkas.


Finally, Dr Latimer and her colleagues from Australia report the creation of an end-of-life assessment tool using an online Delphi technique of international wound experts. After two rounds of the consensus process, they proposed a 16-item tool.


Also included in this issue is a report from your editors-in-chief on the results of the 2022 survey on terminology for terminal skin lesions/ulcers, SCALE (Skin Changes At Life's End), and skin failure. The findings echo the survey findings from 2019. Of the 10 statements, the only one that the majority of respondents still disagreed with is: "The concept of skin failure does not include pressure injuries."


We expect this research will stimulate reflection on current practice and potentially have a positive impact on your care strategies and patient outcomes.


Elizabeth A. Ayello, PhD, MS, RN, CWON, FAAN

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R. Gary Sibbald, MD, MEd, FRCPC, FAAD, JM

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1. Holmes A, Edelstein T, Ayello E, Zulkowski K. A collaborative statewide multifacility initiative reduces pressure ulcers. J Wound Ostomy Continence Nurs 2007;34(3S):S41.2007. [Context Link]


2. Niederhauser A, VanDeusen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz D. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care 2012;25(4):167-88. [Context Link]


3. Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage 2009;55(8):40-8. [Context Link]