Biophysical detection of skin changes to cue pressure injury prevention in nursing homes

摘要 压力性损伤(PRI)，通常位于骨隆起之上，是皮肤和皮肤受损的局部区域。 由压力和剪切力引起的下层软组织。这些痛苦、危险、昂贵和可以预防的 疗养院(NH)居民的伤害与生活质量和死亡率的下降有关。这 嵌入式实用阶梯式楔形群临床试验，采用混合方法，适用于 8 NHS，将检查使用真皮下水分(SEM)评估结果作为护理人员的线索 启动PRI预防。扫描电子显微镜评估，这是一种感知皮肤特征变化的生物物理指标， 通过识别PRI的亚临床症状来检测早期压力损害。扫描电子显微镜的使用是对 当前根据积极的风险评估和/或目视检查启动的PRI预防护理 皮肤变色的症状。当观察到红斑或紫色皮肤时，已经存在显著的损害。滞后时间 压力导致的组织损伤和皮肤变色的视觉检测之间的延迟护理行动 预防PRI。深色肤色的人更难辨别变色，从而造成皮肤损害 对于少数族裔或代表性不足的种族/族裔群体的居民来说，检测比那些 肤色较浅；因此，产生了健康差异。这项研究将把扫描电子显微镜评估纳入PRI 预防-护理标准，并在9个月内进行干预。本研究的目的是：1) 在目测皮肤观察时用扫描电子显微镜确定是否检测到早期压力损伤 居住的骶骨和脚后跟区域在提示启动NH标准预防PRI方面是有效的；2)检查 NH标准PRI预防和结构方程评估与NH居民特征(年龄、 性别、风险、肤色、种族、民族、体重指数、认知状况)以及它们对NH居民个体的影响 关于启动NH标准PRI预防和PRI发生；以及，3)探索扫描电子显微镜的可用性、NH、 护理人员特征影响对早期PRI检测和后续PRI检测的采用和同化 PRI预防实践。目前的NH PRI预防方案和定期安全和护理检查将是 已执行。样本将包括干预开始时的所有居民和在干预期间新入院的居民。 干预期9个月。将使用意向治疗方法对住院患者进行定量分析 分析中包括了整个干预期积累的数据。提示效果将被确定 通过评估与SEM值和PRI发展相关的PRI预防策略的启动 在干预期间。集群/重复测量的混合效应回归模型将使用电子 健康记录数据和扫描电子显微镜评估值被建模以预测PRI预防行动的启动。 定性分析将应用于焦点小组数据，并与线索有效性调查结果进行比较。 研究结果将促进对临床评估的PRI风险水平的了解，并有助于未来的重新设计 预防护理实践和PRI预防指南的改进。

Abstract Pressure injuries (PrIs), commonly located over bony prominences, are local areas of damage to the skin and underlying soft tissue caused by pressure and shear forces. These painful, dangerous, costly, and preventable injuries in nursing home (NH) residents are associated with reduced quality of life and mortality. This embedded pragmatic stepped wedge cluster clinical trial, using a mixed-methods approach for all residents in 8 NHs, will examine use of subepidermal moisture (SEM) assessment results as a cue for nursing staff to initiate PrI prevention. SEM assessment, a biophysical measure that senses changes in skin characteristics, detects early pressure damage by identifying subclinical signs of PrI. SEM use is an innovative addition to current PrI prevention care that is currently initiated upon a positive risk assessment and/or a visual inspection of skin discoloration. Significant damage exists by the time erythema or purple skin is observed. Lag time between pressure-induced tissue damage and visual detection of skin discoloration delays nursing actions to prevent PrIs. Discoloration is more difficult to discern in persons with dark skin tones, making skin damage detection more challenging for residents from minority or under-represented racial/ethnic groups than those with lighter skin tones; thus, producing a health disparity. The study will incorporate SEM assessment into PrI prevention standard-of-care and conduct the intervention over a 9-month period. The study aims are to: 1) determine if early pressure damage detected by SEM assessment at time of visual skin observation of NH resident sacral and heel areas is effective in cueing initiation of NH standard PrI prevention; 2) examine the association between NH standard PrI prevention and SEM assessment and NH residents’ characteristics (age, gender, risk, skin tone, race, ethnicity, BMI, cognitive status) and their interactions on individual NH residents with regard to initiation of NH standard PrI prevention and PrI occurrence; and, 3) explore if SEM usability, NH, and nursing staff characteristics influence the adoption and assimilation of early PrI detection and subsequent PrI prevention practices. Current NH PrI prevention protocols and periodic safety and care checks will be performed. Sample will be comprised of all residents at intervention start and those newly admitted during the 9-month intervention period. An intention to treat approach will be used for quantitative analyses with resident data accrued throughout the intervention period included in analyses. Cueing effectiveness will be determined by evaluating the initiation of PrI prevention strategies in relation to SEM values and the development of PrI during the intervention. Mixed effects regression models for clustered/repeated measures will use electronic health record data and SEM assessment values modeled to predict initiation of PrI prevention actions. Qualitative analyses will be applied to focus group data with comparison to cueing effectiveness findings. Study results will advance knowledge about clinically assessed PrI risk-level and contribute to future redesign of preventive nursing practices and refinement of PrI prevention guidelines.