Pressure Injury Risk Assessment Scales in the Intensive Care Unit: Implementing an ICU Focused Pressure Injury Risk Assessment Scale

[Audio] Pressure Injury Risk Assessment Scales in the Intensive Care Unit: Implementing an ICU Focused Pressure Injury Risk Assessment Scale.

[Audio] The objectives of this presentation and project are to understand the background of pressure injuries in ICU patients. Address health and economic impacts of pressure injuries. Discuss incidence and prevalence of pressure injuries in ICU patients. And Compare pressure injury risk assessment scales used in the ICU..

[Audio] Pressure injuries, also known as "pressure ulcers," are one of the most complex and most serious adverse complications that can occur while a patient is being treated in the hospital. Simply put, a pressure injury is caused by pressure, friction, and/or shearing effects that occur on the patient's tissue over a period of time (Apostolopoulou et al., 2014). Pressure injuries are graded stage 1-4, unstageable, or deep tissue injury. Stage 1: Non-blanchable erythema of intact skin and erythema remains for greater than 1 hour after relief of pressure Stage 2: Partial-thickness loss of skin with exposed dermis Stage 3: Full-thickness loss of skin tissue; subcutaneous skin and muscle may be visible Stage 4: Full-thickness loss of skin tissue; tendons, bone, and joints may be visible Unstageable: Full-thickness loss of skin tissue that is obscured by eschar or slough Deep tissue: Skin that is persistently non-blanchable, with maroon or purple discoloration (Mondragon et. Al., 2024).

[Audio] When discussing preventable adverse events within a hospital, pressure injuries are considered to be one of the most costly and preventable events (Chaboyer et al., 2018) Pressure injuries increase the length of stay for the patient and increase their mortality rate while costing the hospital more money in order to treat the patient (Zhang et al., 2021) According to the National Pressure Ulcer Advisory Panel, which was established in 1986, if proper early prevention and detection methods were put into place, over half of the reported pressure injury cases could have been prevented. The development of a pressure injury is considered a direct indicator of quality of care and the patient's safety (Zhang et al., 2021) Patients in the ICU are considered to be high risk patients when it comes to developing a pressure injury. Patient related factors that contribute to this risk include advanced age, limited activity and mobility, level of consciousness, changes in perfusion parameters and nutritional status, presence of comorbidities such as diabetes/CHF/COPD and chronic renal failure, fecal incontinence, medications such as vasopressors/sedatives/steroids, and low hemoglobin and plasma protein levels (Adibelli & Korkmaz, 2019) With that being said, it is vital to use the correct pressure injury risk assessment scale that takes into consideration all of these risk factors when caring for patients in the ICU..

[Audio] 2.5 million people develop pressure injuries yearly in the United States (Higgins et al., 2020) The incidence of pressure injuries in ICU patients ranges from 2.8% - 53.4% while the incidence for medical-surgical patients is only 2.0% - 8.3% (Zhang et al., 2021) . The prevalence of pressure injuries in ICU patients is 14%-33% (Higgins et al., 2020) These numbers make it very clear that ICU patients are high risk patients when it comes to developing a pressure injury..

[Audio] Pressure injuries are associated with significant health burdens and are preventable. Healthcare providers use risk assessment scales to identify patients at higher risk for pressure injuries and determine the amount and type of preventative interventions to decrease the incidence, or severity of pressure ulcers. Risk assessment scales, along with the clinical judgement and assessment of healthcare providers can help identify high risk patients and prevent pressure injuries..

[Audio] When it comes to the cost of treating pressure injuries, on average, each pressure injury cost the hospital $50,000 (Higgins et al., 2020) Yearly, the average cost in the United States to treat pressure injuries is $26.8 billion (Higgins et al., 2020) President Bush signed the Deficit Reduction Act of 2005 which allowed for quality adjustment of Medicare payments for inpatient hospital services. The Deficit Reduction Act of 2005 is important in regard to pressure injuries because it required the Secretary of Health and Human Services to identify two hospital acquired conditions that could have been prevented through the application of evidence based guidelines and would be subject to the adjustment in payment. These acquired conditions were then given the name of "never event" with pressure injuries being one of them. Three years after the Deficit Reduction Act of 2005 was signed, the Centers for Medicare & Medicaid discontinued reimbursement to hospitals for hospital-acquired pressure injuries..

[Audio] The Braden Scale was created in 1987 for the general patient population (Higgins et al., 2020) The Braden Scale is a subjective pressure injury risk assessment scale takes six factors into consideration when assessing a patients risk of developing a pressure injury: sensory perception, moisture, activity, mobility, friction & shear, and nutrition status (Higgins et al., 2020) Scores for each factor range from 1 (least favorable) to 4 (most favorable condition) except for friction and shear for which a score of 3 indicates the most favorable condition (Higgins et al., 2020) The range of overall scores is 6-23. The lower the score is, the higher risk the patient is to develop a pressure injury (Higgins et al., 2020) The Braden Scale has an overall specificity, sensitivity, negative predictive value, and positive predictive value of 95%, 17%, 78%, and 53% respectively (Higgins et al., 2020) Simply put, these numbers indicate that the Braden Scale demonstrates poor predictive qualities along with poor discriminatory ability in the ICU patient population (Higgins et al., 2020).

[Audio] Braden Scale Adult (2022). [Chart]. NPCS Clinical Resources. https://www.mghpcs.org/EED/SK/resources.shtml.

[Audio] The Jackson Cubbin Scale was created in 1991 and later revised in 1999 (Higgins et al., 2020) This scale is an objective scale that was made specifically for patients in the ICU (Higgins et al., 2020) Takes 12 domains into consideration when assessing a patients risk for developing a pressure injury: age, weight, medical history, general skin condition, mental status, mobility, hemodynamic status, respiratory status, oxygen requirements, nutrition, incontinence, and hygiene (Higgins et al., 2020) Each domain is scored from 1 (increased risk) to 4 (decreased risk) with a range of scores being 9-48 Lower score indicates higher risk for patient to develop a pressure injury Additionally, there are 1 point deductions for trips to the OR or imaging (CT or MRI) that happen in the preceding 48 hours, blood product transfusion in the preceding 24 hours, and hypothermia (core temp of less than or equal to 35 degrees Celsius) The Jackson Cubbin Scale has an overall specificity, sensitivity, negative predictive value, and positive predictive value of 92%, 54%, 87%, and 66% Indicating that it is a more suitable pressure injury risk assessment scale to use in the ICU when compared to the Braden Scale (Higgins et al., 2020).

[Audio] Kim, E., Choi, M., Lee, J., & Kim, Y. A. (2013). Reusability of EMR data for applying cubbin and Jackson pressure ulcer risk assessment scale in critical care patients. Healthcare Informatics Research, 19 (4), 261-270. https://doi.org/10.4258/hir.2013.19.4.261.

[Audio] When comparing the difference in the Braden scale verse the Jackson Cubbin scale it is important to know why the different scales should be used among different hospital populations. The Braden scale is a general risk assessment scale while the Jackson Cubbin scale is created specifically for ICU patient population due to the significant limitations when it comes to assessing them (Zhang et al., 2021). The Braden scale scores are based on 6 risk factors of the patient: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This scale takes the following twelve factors into consideration: age, weight, past medical history, general skin condition, mental condition, mobility, hemodynamics, respiratory status, oxygen requirement, nutrition, incontinence, and hygiene (Adibelli & Korkmaz, 2019). The Jackson Cubbin also allows for deductions in points based on if the patient went to the operating room or has imaging such as a computed tomography scan (CT). According to the National Pressure Ulcer Advisory Panel, which was created in 1986, if early prevention and detection methods were put into place, over half of the reported pressure injury cases could have been prevented. This is why the appropriate use of risk assessment tools is important in the prevention of pressure ulcers, and why we are incorporating the Jackson-Cubbin Scale into practice in ICU patient populations..