Pressure Ulcer

BackgroundPressure injuries (PIs) pose a substantial healthcare burden and incur significant costs worldwide. Several risk prediction tools to allow timely implementation of preventive measures and a subsequent reduction in healthcare system burden are available and in use. The ability of risk prediction tools to correctly identify those at high risk of PI (prognostic accuracy) and to have a clinically significant impact on patient management and outcomes (effectiveness) is not clear. We aimed to evaluate the prognostic accuracy and clinical effectiveness of risk prediction tools for PI and to identify gaps in the literature.Methods and findingsThe umbrella review was conducted according to Cochrane guidance. Systematic reviews (SRs) evaluating the accuracy or clinical effectiveness of adult PI risk prediction tools in any clinical settings were eligible. Studies on paediatric tools, sensor-only tools, or staging/diagnosis of existing PIs were excluded. MEDLINE, Embase, CINAHL, and EPISTEMONIKOS were searched (inception to June 2024) to identify relevant SRs, as well as Google Scholar (2013 to 2024) and reference lists. Methodological quality was assessed using adapted AMSTAR-2 criteria. Results were described narratively. We identified 26 SRs meeting all eligibility criteria with 19 SRs assessing prognostic accuracy and 11 assessing clinical effectiveness of risk prediction tools for PI (4 SRs assessed both aspects). The 19 SRs of prognostic accuracy evaluated 70 tools (39 scales and 31 machine learning (ML) models), with the Braden, Norton, Waterlow, Cubbin-Jackson scales (and modifications thereof) the most evaluated tools. Meta-analyses from a focused set of included SRs showed that the scales had sensitivities and specificities ranging from 53% to 97% and 46% to 84%, respectively. Only 2/19 (11%) SRs performed appropriate statistical synthesis and quality assessment. Two SRs assessing machine learning-based algorithms reported high prognostic accuracy estimates, but some of which were sourced from the same data within which the models were developed, leading to potentially overoptimistic results. Two randomised trials assessing the effect of PI risk assessment tools (within the full test-intervention-outcome pathway) on the incidence of PIs were identified from the 11 SRs of clinical effectiveness; both were included in a Cochrane SR and assessed as high risk of bias. Both trials found no evidence of an effect on PI incidence. Limitations included the use of the AMSTAR-2 criteria, which may have overly focused on reporting quality rather than methodological quality, compounded by the poor reporting quality of included SRs and that SRs were not excluded based on low AMSTAR-2 ratings (in order to provide a comprehensive overview). Additionally, diagnostic test accuracy principles, rather than prognostic modelling approaches were heavily relied upon, which do not account for the temporal nature of prediction.ConclusionsAvailable systematic reviews suggest a lack of high-quality evidence for the accuracy of risk prediction tools for PI and limited reliable evidence for their use leading to a reduction in incidence of PI. Further research is needed to establish the clinical effectiveness of appropriately developed and validated risk prediction tools for PI.

ObjectiveThis article presents a literature review to explore and analyze the current situation of pressure ulcers or lesions or decubitus ulcers, pathophysiological, epidemiological aspects, and risk factors. The progress in evidence of the effectiveness of preventive repositioning in the appearance of these lesions in vulnerable hospitalized patients is also evaluated.MethodsDatabases were reviewed in non-systematic manner, including the Cochrane Wounds Specialized Register; Medline, Scopus, PubMed, the Cochrane Central Register of Controlled Trials; MEDLINE (Ovid); EMBASE (Ovid), Web of Science, SciELO, and Lilacs. The general search terms included [pressure ulcers or pressure lesions or decubitus ulcers] and [prevention or preventive] and [repositioning or positioning or position changes or postural change] and [patient at risk or vulnerable] and [hospitalized or ICU or intensive care]. Systematic literature reviews, randomized clinical trials, observational studies, cost-effectiveness and qualitative studies in English or Spanish were included.ResultsAlthough globally, the incidence, prevalence, and years of disability associated to these lesions has diminished between 1990 and 2019, the high impact on health persists. Evidence found on the effectiveness of repositioning in preventing pressure ulcers and health associated costs has been evaluated with certainty between low and very low, as a result of conducting research with serious methodological limitations that report results with high inaccuracy.ConclusionThe findings reported present that these lesions persist at hospital level and continue being a global social and health problem with high impact on health budgets. Likewise, there is a need to develop greater quality research on prevention strategies, such as repositioning, which validate their effectiveness, and justify their use.

BackgroundErythema, an early visual indicator of tissue damage preceding pressure injuries (PrIs), presents as redness in light skin tones but is harder to detect in dark skin tones. While thermography shows promise for early PrI detection, validation across different skin tones remains limited. Furthermore, most protocols and models have been developed under highly controlled conditions.ObjectiveTo evaluate how environmental and technical factors (i.e., patient positioning, lighting, distance, camera type) and skin tone impact thermal imaging measurements and temperature change.MethodsThis pre-post experimental study enrolled 35 healthy adults (30 with Monk Skin Tone Scale ≥6). Melanin Index was measured on the volar forearm using the SkinColorCatch®. After baseline imaging, a 15.5°C cooling stone was placed on one posterior superior iliac spine (PSIS) for 5 minutes. Thermal images were then collected with either the FLIR E8-XT or the FLIR ONE Pro camera under varied conditions: two lighting types (overhead room versus localized LED ring light), three postures (side-lying, side-lying with forward knee placement, and side-lying with rearward knee placement), and two camera-to-body distances (35 cm and 50 cm from the PSIS). The cooling/imaging procedure was repeated using the alternate camera, and data were analyzed using mixed-methods model.ResultsTemperature change was effectively detected across all skin tones, with cooling resulting in a -3.7 ± 1.2°C difference between the region of interest (ROI) and control region. Camera type significantly affected measurements, with the ONE Pro recording 1.04°C less cooling than the E8-XT. Distance had minimal impact (0.11°C cooler at 50 cm vs 35 cm at baseline), with no significant difference when comparing ROI to control regions, while lighting and posture had no impact on measurements. Skin tone varied by cooling measurement, with higher melanin levels showing greater temperature changes. A 0.98°C difference was observed between the lightest and darkest skin tone groups.DiscussionOur findings confirm thermal imaging's robustness across varied environments, with the minor distance effects mitigated through perpendicular measurements and relative temperature comparisons. Significant discrepancies between thermal cameras (>1°C) highlight that these technologies cannot be used interchangeably when establishing thresholds. While effective across all skin tones, the observed differences in cooling response suggest tailored thresholds may be necessary for darker skin tones. Future research should focus on clinical validation across diverse populations to enhance PrI detection accuracy.

There are few previous studies regarding recurrent pressure injuries, most of which investigate surgical outcomes. From the perspective of the healthcare system, recurrent pressure ulcers may indicate shortcomings in quality, as preventive measures have failed not just once, but on several occasions. We aimed to examine how healthcare professionals working with wound care in specialised inpatient care perceived the causes of recurrent pressure injuries in patients with spinal cord injuries. A phenomenographic study using in-depth interviews was conducted. We identified four categories of the experienced causes of recurrent pressure injuries based on the respondents' subjective accounts: recurrent wounds are due to physical and mental vulnerability in the patient; recurrent wounds are due to a lack of compliance in patients and professionals; recurrent wounds are the result of fruitless endeavours to prevent them; recurrent wounds are due to neglect in healthcare. The causes were described as originating from different structural levels within society. However, preventive measures were primarily perceived as having been assigned at the patient and healthcare staff levels. The elderly were described as particularly vulnerable, whilst care and community interventions declined with increasing age. The participants emphasised that the changes in clinical practice that need to be prioritised primarily concern fundamental principles, in particular person-centred and inclusive care. Furthermore, a clearer division of responsibilities was highlighted as crucial, as patients in need of multimodal interventions have been found to fall between the cracks in a diagnosis-based healthcare system.