heel pressure injury risk factors in the hospitalized patient · heel pressure injury risk factors...
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HEEL PRESSURE INJURY RISK FACTORS IN THE HOSPITALIZED PATIENTBarbara Delmore, PhD, RN, CWCN, MAPWCA, IIWCC-NYU
NYULH 23rd Annual Nursing Research Conference
June 18, 2019
Disclosures
• Board of Directors: National Pressure Ulcer Advisory Panel
& American Professional Wound Care Association
• Advances in Skin & Wound Care, Editorial Advisory Board
• Monument Analytics, Consultant
The study was funded by Sage Products, LLC. The funding
source was not involved in study design, monitoring, data
collection, statistical analyses, interpretation of results, or
manuscript writing.
©Delmore 2019
HPI Risk Factors in the Hospitalized Patient - Background
Heels are a common PI location
• #2 site1,2,3,4,5,6
• Most frequently occurring location for DTPIs (41%) compared
to sacrum (19%) & buttocks (13%)7
• Despite global efforts to occurrence, they persist
HPI Risk Factors in the Hospitalized Patient - Purpose
• Primary aim
–Replicate our previous research, which found 4
significant & independent predictors for HPIs in the
hospitalized patient, using a larger, more diverse
population:
• DM, Vascular Disease, Admission Braden <18,
Immobility8
• Secondary aim
–Create an enabler for a heel-specific assessment
Inclusion Criteria Exclusion Criteria
• Patients w/heel vascular wounds
• Obstetric & Psychiatric patients
• Children <18 years old
• Prone to device-related PIs9,10,11
• Previous research - 0.1%8
HPI Risk Factors in the Hospitalized Patient
Hospitalized adult patients > 18
years old (w/& w/out HPIs)
©Delmore 2019
Design: Retrospective, case-control study (main & validation analyses) using
the NY Statewide Planning & Research Cooperative System (SPARCS) –
1/1/14 – 6/30/15
HPI Risk Factors in the Hospitalized Patient – Sample Size
SPARCS
(1/1/2014-6/30/2015)
©Delmore 2019
Removed
2,301
• CAPIs
• CAPIs & HAPIs mix
• Incomplete HPI data
364
1,937
403 cases HAHPIs
1,534 controls (w/out any PIs)
Main Analysis – 1,697
323 cases w/ HPIs
1,374 controls w/out HPIs
Validation Analysis– 240
80 cases w/ HPIs
160 controls w/out HPIs
• Impaired nutrition (ICD-9 codes)
• Obesity conditions (ICD-9 codes)
• Vascular disease (ICD-9 codes)
• ESRD (ICD-9 codes)
• Neuropathy (ICD-9 codes)
• Perfusion issues (ICD-9 codes)
• DM diagnosis I/II (ICD-9 codes)
• Surgery (ICD-9 codes)
• Immobility (ICD-9 codes)
• Mechanical ventilation (ICD-9 codes)
• ICU stay
• Lower extremity fractures (ICD-9 codes)
• Age
HPI Risk Factors in the Hospitalized Patient - Variables
Demographics
sex, race, age, admitting diagnosis, TTL LOS
©Delmore 2019
HPI Risk Factors in the Hospitalized Patient - Methods
Main Analysis
• Series of univariate & bivariate analyses - select predictor variables
• Series of forward stepwise regression analyses - select variables
significantly & independently associated w/HPI
• Final forward stepwise regression analysis - create final model
• ROC curve to assess model accuracy
Validation Analysis
• Model tested - data unrelated to model development
HPI Risk Factors in the Hospitalized Patient - Results
Demographics Main analysis (n = 1,697) Validation analysis (n = 240)
Cases (n = 323) Controls (n = 1,374) Cases (n = 80) Controls (n = 160)
Variable # patients (%) # patients (%) # patients (%) # patients (%)
Age, mean (sd) 74.4 (15.4) 55.8 (21.5) 74.4 (17.2) 52.9 (18.4)
Age
18 - 64 78 (24.1) 852 (62.0) 17 (21.3) 114 (71.3)
> 65 245 (75.9) 522 (38.0) 63 (78.8) 46 (28.7)
Sex
Female 175 (54.2) 838 (61.0) 47 (58.8) 91 (56.9)
Male 148 (45.8) 536 (39.0) 33 (41.3) 69 (43.1)
Ethnicity
Spanish/Hispanic origin 1 (0.3) 2 (0.1) 0 (0.0) 1 (0.6)
Other 305 (94.4) 1295 (94.3) 78 (97.5) 155 (96.9)
Unknown 17 (5.3) 70 (5.1) 2 (2.5) 4 (2.5)
Length of stay (median days) 18.0 3.0 20.5 3.0
HPI Risk Factors in the Hospitalized Patient - Results
©Delmore 2019
Main (n=323) Validation (n=80)
HPI stage (ICD-9) # PIs (%) #PIs (%)
Stage 1 (707.21) 69 (21.4) 22 (27.5)
Stage 2 (707.22) 99 (30.7) 21 (26.3)
Stage 3 (707.23) 16 (5.0) 4 (5.0)
Stage 4 (707.24) 13 (4.0) 4 (5.0)
Unstageable (707.25) 92 (28.5) 25 (31.3)
Unspecified (707.20) 34 (10.5) 4 (5.0)
HPI Risk Factors in the Hospitalized Patient - Results
©Delmore 2019
Predictor Variable Regression
Coefficient
SE P Odds Ratio 95% CIs
DM 0.33 0.16 0.03 1.4 1.0 - 1.9
Vascular Disease 1.12 0.27 0.001 3.1 1.8 – 5.2
Perfusion Issues 1.02 0.16 <0.001 2.8 2.1 – 3.8
Impaired Nutrition 1.92 0.26 <0.001 6.9 4.1 – 11.5
Age > 65 1.20 0.16 <0.001 3.3 2.4 – 4.6
Mechanical Ventilation 2.05 0.32 <0.001 7.7 4.2 – 14.3
Surgery 0.61 0.16 <0.001 1.8 1.3 – 2.5
Main analysis results - significant & independent predictors of HPI, N=1,69712
HPI Risk Factors in the Hospitalized Patient - Results
©Delmore 2019
AUC=84.2
HPI Risk Factors in the Hospitalized Patient - Limitations
• Retrospective design
• Dataset
–Data quality issues
–Coding errors
©Delmore 2019
HPI Risk Factors in the Hospitalized Patient - Summary
• Primary Aim
–Identified 7 risk factors
• Secondary Aim
–Enabler created (mnemonic)
©Delmore 2019
Co-Investigators
Dr. Elizabeth Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN
Andy S. Chu, MS, RD, CDN, CNSC, FAND
Data Analyst
Daniel Smith, MA
Biostatistician
Linda Rolnitzky, MS
Thank You Research Team!
THANK YOU
References
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Care, 20(4), 208, 210, 212, 214, 216, 218–220. https://doi.org/10.1097/01.ASW.0000266646.43159.99
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Journal of Nursing, 117(12), 36–45. https://doi.org/10.1097/01.NAJ.0000527460.93222.31
11. Delmore, B., Deppisch, M., Sylvia, C., Luna-Anderson, C., & Nie, A.M. (in press). Pressure Injuries in the Pediatric Population: A National
Pressure Ulcer Advisory Panel White Paper. Advances in Skin & Wound Care.
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Care (in Press).