Pressure injuries are a pervasive problem.

They present a real cost for patients physically, psychologically and monetarily. Plus, pressure injuries have an annual financial burden estimated at $11 billion per year in the U.S., especially in the ICU.

A study published in June 2019 by the journal Critical Care Nurse reports pressure injuries present at ICU admission are associated with longer hospital stays. They also have a modest association with higher in-hospital mortality rates.

“I was looking for an unambiguous clinical marker that could predict patient outcomes and mortality in ICU patients,” said William T. McGee, MD, MHA, associate professor of medicine and surgery at the University of Massachusetts Medical School.

He said different modeling tools try to predict outcomes and mortality in ICU patients, but they are not used routinely for all patients at all hospitals.

Clinical markers at ICU admission

McGee said one predictive tool known as the Acute Physiology and Chronic Health Evaluation (APACHE) and Mortality Prediction Model performs well at predicting mortality rates. However, one drawback is it cannot be implemented upon admission.

“The APACHE requires the use of data collected during the patient’s first 24 hours in the ICU,” said McGee, who also is an intensivist at Baystate Medical Center in Springfield, Mass.

On the other hand, McGee said having a clear clinical marker that could identify higher-risk patients immediately upon ICU admission can be extremely helpful.

A clinical finding, such as the presence of pressure injuiries, identifies a group of patients who, because of their increased age, frail condition, immobility and perfusion problems, are at a higher risk of:

  • Longer hospital stays
  • Additional care
  • Additional resources
  • Possible higher rates of mortality

McGee said bedside nurses have always provided valuable input in helping him connect the possible association between the presence of pressure injuries and poor outcomes in ICU patients.

These anecdotal observations provided McGee the impetus to formally study this possible association further.

“The nurses are the ones who identify the pressure injuries upon admission and provide care at the bedside,” he said. “Their insight into the association between pressure injuries and the increased risk for these patients with longer stays and increased mortality rates was integral and highlights the continued need for thorough skin assessments.”

Pressure injury research

The research, “Pressure Injuries at Intensive Care Unit Admission as a Prognostic Indicator of Patient Outcomes,” was conducted as a retrospective study that examined adult patient admissions from Oct. 1, 2010 to April 30, 2012 at Baystate Medical Center’s medical-surgical ICU, according to McGee.

The study initially involved an assessment of 3,079 patient records from the ICU from that time period. Patients with invalid APACHE scores on the first day, and those who were readmitted, were excluded.

This resulted in a final assessment of 2,723 patients who met the study’s criteria. Of these patients, 180 presented with pressure injuries upon admission to the ICU, McGee said.

“Patients with pressure injuries present at admission had a hospital stay that was 3.1 days longer, and a slightly higher mortality rate once we adjusted other variables,” he said.

Patients with pressure injuries present on ICU admission impact resource utilization with ICU beds, staff and equipment. Plus, many of the patients came from skilled nursing facilities and were typically going back upon discharge from the hospital, according to the study. 

“While many ICU patients in the U.S. may survive their hospital stay, follow-up is generally not done over the long term to assess how many patients are still alive three, six or 12 months after their ICU discharge, nor is their subsequent quality of life assessed,” McGee said.

Questions to consider

Modern medicine can do a lot to help patients survive the acute problem that brought them to the ICU.

However, the flip side is patients go through a lot with ICU care and can experience pain and stress from the treatments they receive.

McGee asks medical professionals to consider two important questions:

  1. Was the patient’s stay free of suffering?
  2. Would the patient do it again?

He hopes having an unambiguous way to identify patients who are more at risk for poor outcomes may lead some physicians to discuss other options for care with patients sooner.

“One example is going home with palliative care and oral antibiotics for an infection, rather than enduring the rigors of ICU care,” McGee said. “There needs to be a titrated balance. We can help patients survive the ICU but at what cost, from a patient suffering standpoint?”

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Carole Jakucs, MSN, RN, PHN, CDCES

Carole Jakucs, MSN, RN, PHN, CDCES, is a freelance writer and diabetes educator. Her background in nursing includes tenures in healthcare management and as a care provider. She has worked in med/surg/telemetry, a pediatric emergency department and college health.

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