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Skin Integrity and Pressure Injuries

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Hsieh J, Benton B, Titus L, Gabison S, McIntyre A, Wolfe D, Teasell R. (2020). Skin Integrity and Pressure Injuries Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 7.0. 1-123.


1.0  Executive Summary

No matter the method used to calculate incidence and prevelance of pressure injuries, the result is always too high for such a preventable complication of SCI. The inordinate cost to quality of life of the individual with an SCI and to healthcare expeditures, necessitates much more focus, understanding and management of pressure injuries, This is particularly true in the acute phase of SCI where care-related causes are the major culprit.  That said, the acute phase after initial injury is a period of time with multiple competing priorities.  Nevertheless, the healthcare system needs to find balance amongst competing priorities. Thereafter, in the chronic phase post SCI, the most vulnerable population has been identified as poorly educated, unemployed males.  Understanding the most vulnerable allows for targeted interventions. It’s also important to note that the complex interactions between the plethora of demographic, medical/clinical, functional and psychosocial risk factors do not discriminate amongst all who live with SCI. The use of risk assessment tools designed for SCI may be helpful for customized prevention strategies.  Furthermore, ultrasonography, magnetic resonance imaging and biomarkers are emerging technologies useful for detection and targeted treatment. However, even without high technology, long-standing methods such as pressure mapping, education and self-mangement have proven to be effective preventative and management strategies that have stood the test of time.  Despite the best efforts to prevent the onset of a pressure injury, they continue to emerge over the life of the person with SCI and unfortunately development of a pressure injury leads to increased risk of recurrence.

Once the injured skin has been identified, early stage injuries can often be managed with pressure relief while later stage injuries may require direct treatment (e.g. electrical stimulation, laser, ultrasonography, non-thermal pulsed electromagnetic energy, topical negative pressure, normothermia, recombinant human erythropoietin, anabolic steroid therapy, effectiveness of various dressings, maggot therapy, topical oxygen, surgery and other herbal remedies) with varying effectiveness. However, level 1 evidence only supports a subset of these treatments (e.g. electrical stimulation, laser, ultrasonography,pulsed electromagnetic energy, topical negative pressure) and only for select grades of pressure injuries.  Interestingly, education is supported by level 1b evidence to be effective in empowering individuals in detecting and managing pressure injuries, especially in those where one has not yet developed.  This is in keeping with a trend to self-management in chronic diseases, especially with health care provider support, to mitigate for the negative impact on quality of life and healthcare resources as a result of pressure injuries secondary to SCI.

Going forward, the SCI research community needs to continue to investigate intervention effectiveness including comparisons between interventions.  Below is a discussion regarding gaps in the evidence intended to improve on the body of evidence that already exists for the prevention, detection and management of SCI related pressure injuries.

 

Gaps in the Evidence

As identified by the National Institute for Health Research (NIHR) James Lind Alliance (JLA) Priority Setting Partnership (PSP) on complex wounds and with this came the particular challenges of involving people with pressure ulcers in research associated with their age, multiple morbidities and social isolation. Indeed the service users who participated in this research prioritization exercise were generally younger and fitter than those most at risk of pressure ulcers, nevertheless the PSP succeeded in identifying research priorities which capture the views of patients, carers and healthcare professionals (NIHR JLA PSP, 2019). The following research priorities identified were:

  1. How effective is repositioning in the prevention of pressure injuries?
  2. How effective at preventing pressure injuries is involving patients, family and lay carers in patient care?
  3. Does the education of health and social care staff on prevention lead to a reduction in the incidence of pressure injuries and, if so, which are the most effective education programmes (at organisational and health/social care level)?
  4. What is the relative effectiveness of the different types of pressure relieving beds, mattresses, overlays, heel protectors and cushions (including cushions for electric and self-propelling wheelchairs) in preventing pressure injuries?
  5. What impact do different service models have on the incidence of pressure injuries including staffing levels, continuity of care [an on-going relationship with same staff members] and the current organisation of nursing care in hospitals?
  6. What are the best service models (and are they sufficiently accessible) to ensure that patients with pressure injuries receive the best treatment outcomes (including whether getting people with pressure ulcers and their carers more involved in their own pressure ulcer management improves ulcer healing and if so, the most effective models of engagement)?
  7. For wheelchair users sitting on a pressure injuries, how effective is bed rest in promoting pressure ulcer healing?
  8. How effective are wound dressings in the promotion of pressure injury healing?
  9. Does regular turning of patients in bed promote healing of pressure injuries?
  10. Does improving diet (eating) and hydration (drinking) promote pressure injury healing?
  11. How effective are surgical operations to close pressure injuries?
  12. How effective are topical skin care products and skin care regimes at preventing pressure injuries?