Pressure Ulcer Risk Assessment
5.4 Conclusions
Recently, the development and implementation of the COHMON (conscious level, mobility, hemodynamics, oxygen- ation, nutrition) index opened a new opportunity in the evaluation of PIs’ risk. This tool includes five items (level of consciousness, mobility, hemodynamic, oxygenation, and nutrition) scored from 1 to 4 points (the higher is the score, the higher is the risk). When compared with traditional scoring systems, the COHMON index showed a better sensitivity and specificity, positive and negative predictive values, and very good reliability both for single items and the global index [36]. When compared with Braden, Norton, and Waterlow scales, this index also showed the highest inter- rater reliability and agreement [37].
Irrespective of the chosen PIs’ risk assessment tool, use of vasopressors (vasopressin and norepinephrine), mean arterial pressure <60 mmHg, cardiac arrest, and prolonged MV (>72 h) has been associated with PIs’ development [38], thus suggesting the need for a higher vigilance in patients with those clinical and treatment features.
Currently, there is no strong evidence regarding optimal PIs’
risk reassessment intervals. Widely accepted and published clini- cal standards suggest a weekly revaluation. However, in certain clinical situations, risk assessment scales may have limits, since they don’t consider PIs’ risk associated with the use of devices.
patients’ positioning, progressive mobilization, and active collabora- tion during physiotherapy interventions. These activities should become nursing priorities in the ICUs’ dynamic frameworks, since there are scarce contraindications to start progressive mobility pro- grams during acuity conditions. These are hemodynamic instability, intracranial hypertension, and severe multiple bone injuries. Another major positive consequence of early mobilization is the pressure ulcers (pressure injuries—PIs) prevention in ICU.
Currently the use of Braden scale for PIs’ risk assessment in critical care patients seems not to be further recommended because it has a poor accuracy in predicting PIs, mainly related to the lack of consideration for ICU-specific risk factors such as MV, hypo- tension, cardiovascular instability, and ICU-LOS. Even the Cubbin-Jackson scale seems to have important limitations in some ICU populations. Recently, a new scale, called COHMON (con- scious level, mobility, hemodynamics, oxygenation, nutrition) index for PIs’ risk assessment in ICU, seems to be promising.
Take-Home Messages
• ICU-AW is one of the most underrated complications in ICU patients.
• Early mobilization programs and optimal nutritional support are the main interventions to prevent the development of ICU-AW.
• Prevention of PIs is an established nursing quality indicator.
• Multidisciplinary approaches to reduce the risk of ICU-AW and HAPU are needed.
References
1. Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: mobilizing patients in the intensive care unit—from patho- physiology to clinical trials. Crit Care. 2009;13:216. https://doi.
org/10.1186/cc7885.
2. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treat- ment needing more careful evaluation. Lancet. 1999;354:1229–33.
https://doi.org/10.1016/S0140-6736(98)10063-6.
3. McPeake J, Quasim T. Quality of life in intensive care survivors. Br J Nurs. 2015;24:1016. 10.12968/bjon.2015.24.20.1016.
4. Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014;4:Cd009958. https://doi.
org/10.1002/14651858.CD009958.pub2.
5. Fletcher SN, Kennedy DD, Ghosh IR, Misra VP, Kiff K, Coakley JH, et al. Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness. Crit Care Med.
2003;31:1012–6. https://doi.org/10.1097/01.CCM.0000053651 .38421.D9.
6. Asfour HI. Contributing factors for acquired muscle weakness in the intensive care unit. J Nurs Educ Pract. 2016;6:102–11. https://doi.
org/10.5430/jnep.V6n8p102.
7. Rukstele CD, Gagnon MM. Making strides in preventing ICU-acquired weakness involving family in early progressive mobility. Crit Care Nurs Q. 2013;36:141–7. https://doi.org/10.1097/
CNQ.0b013e31827539cc.
8. Fan E. Critical illness neuromyopathy and the role of physical therapy and rehabilitation in critically ill patients. Respir Care. 2012;57:933–
44. https://doi.org/10.4187/respcare.01634.
9. SE H, Kannus P, Natri A, Latvala K, Järvinen MJ. Isokinetic perfor- mance of the thigh muscles after tibial plateau fractures. Int Orthop.
1997;21:323–6.
10. Hollander JM, Mechanick JI. Nutrition support and the chronic critical illness syndrome. Nutr Clin Pract. 2006;21:587–604. https://doi.org/10 .1177/0115426506021006587.
11. Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and criti- cal illness myopathy. Cochrane Database Syst Rev. 2014;30:CD006832.
https://doi.org/10.1002/14651858.CD006832.pub3.
12. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238–43. https://doi.
org/10.1097/CCM.0b013e318180b90e.
13. Foster J. Complications of sedation in critical illness: an update. Crit Care Nurs Clin North Am. 2016;28:227–39. https://doi.org/10.1016/j.
cnc.2016.02.003.
14. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, et al.
Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on physiotherapy for critically ill patients.
Intensive Care Med. 2008;34:1188–99. https://doi.org/10.1007/
s00134-008-1026-7.
15. Krupp AE, Monfre J. Pressure ulcers in the ICU patient: an update on prevention and treatment. Curr Infect Dis Rep. 2015;17:468. https://
doi.org/10.1007/s11908-015-0468-7.
16. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park; 2014.
17. National Pressure Ulcer Advisory Panel (NPUAP). Announcement of change in terminology from pressure ulcer to pressure injury. 2016.
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap- announces-a-change-in-terminology-from-pressure-ulcer-to-pressure- injury-and-updates-the-stages-of-pressure-injury/. Accessed 7 Apr 2017.
18. Jugun K, Richard JC, Lipsky BA, Kressmann B, Pittet-Cuenod B, Suvà D, et al. Factors associated with treatment failure of infected pressure sores. Ann Surg. 2016;264:399–403. https://doi.org/10.1097/
SLA.0000000000001497.
19. Rennert R, Golinko M, Yan A, Flattau A, Tomic-Canic M, Brem H. Developing and evaluating outcomes of an evidence-based protocol for the treatment of osteomyelitis in Stage IV pressure ulcers: literature and wound electronic medical record database review. Ostomy Wound Manage. 2009;55:42–53.
20. Brunel AS, Lamy B, Cyteval C, Perrochia H, Téot L, Masson R, et al.
OSTEAR Study Group. Diagnosing pelvic osteomyelitis beneath pres- sure ulcers in spinal cord injured patients: a prospective study. Clin Microbiol Infect. 2016;22:267.E1–8. https://doi.org/10.1016/j.
cmi.2015.11.005.
21. Schiffman J, Golinko MS, Yan A, Flattau A, Tomic-Canic M, Brem H. Operational debridement of pressure ulcers. World J Surg.
2009;33:1396–402. https://doi.org/10.1007/s00268-009-0024-4.
22. Behrendt R, Ghaznavi AM, Mahan M, Craft S, Siddiqui A. Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit. Am J Crit Care. 2014;23:127–33.
https://doi.org/10.4037/ajcc2014192.
23. Cremasco MF, Wenzel F, Zanei SS, Whitaker IY. Pressure ulcers in the intensive care unit: the relationship between nursing workload, illness
severity and pressure ulcer risk. J Clin Nurs. 2013;22:2183–91. https://
doi.org/10.1111/j.1365-2702.2012.04216.x.
24. Barrois B, Labalette C, Rousseau P, Corbin A, Colin D, Allaert F, et al.
A national prevalence study of pressure ulcers in the French hospital inpatients. J Wound Care. 2008;17:373–6, 378–9. 10.12968/
jowc.2008.17.9.30934.
25. Martin E. Concise medical dictionary. 9th ed. Oxford: Oxford University Press; 2015. Market House Books
26. National Institute for Health and Care Excellence (NICE). Pressure ulcers. https://www.nice.org.uk/guidance/qs89 . Accessed 7 Apr 2017.
27. Bredesen IM, Bjøro K, Gunningberg L, Hofoss D. Effect of e-learning program on risk assessment and pressure ulcer classification—a ran- domized study. Nurse Educ Today. 2016;40:191–7. https://doi.
org/10.1016/j.nedt.2016.03.008.
28. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987;36:205–10.
29. Swafford K, Culpepper R, Dunn C. Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an inten- sive care unit. Am J Crit Care. 2016;25:152–5. https://doi.org/10.4037/
ajcc2016963.
30. Serpa LF, Santos VL, Campanili TC, Queiroz M. Predictive validity of the Braden scale for pressure ulcer risk in critical care patients. Rev Lat Am Enfermagem. 2011;19:50–7.
31. Cho I, Noh M. Braden Scale: evaluation of clinical usefulness in an intensive care unit. J Adv Nurs. 2010;66:293–302. https://doi.
org/10.1111/j.1365-2648.2009.05153.x.
32. Hyun S, Vermillion B, Newton C, Fall M, Li X, Kaewprag P, et al.
Predictive validity of the Braden scale for patients in intensive care units. Am J Crit Care. 2013;22:514–20. https://doi.org/10.4037/
ajcc2013991.
33. Jackson C. The revised Jackson/Cubbin pressure area risk calculator.
Intensive Crit Care Nurs. 1999;15:169–75.
34. Wheeler H. Positioning: one good turn after another? Nurs Crit Care.
1997;2:129–31.
35. Ahtiala MH, Soppi E, Kivimäki R. Critical evaluation of the Jackson/
Cubbin pressure ulcer risk scale—a secondary analysis of a retrospec- tive cohort study population of intensive care patients. Ostomy Wound Manage. 2016;62:24–33.
36. Cobos Vargas A, Garofano Jerez JR, Guardia Mesa MF, Carrasco Muriel C, Lopez Perez F, Gonzalez Ramırez AR, et al. Design and vali- dation of a new rating scale (COMHON Index) to estimate the risk of
pressure ulcer in patients attended in critical care units. Connect: The World of Critical Care. Nursing. 2011;8:41.
37. Fulbrook P, Anderson A. Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales. J Adv Nurs. 2016;72:680–92. https://doi.org/10.1111/
jan.12825.
38. Cox J, Roche S. Vasopressors and development of pressure ulcers in adult critical care patients. Am J Crit Care. 2015;24:501–10. https://
doi.org/10.4037/ajcc2015123.