Background
Pressure injuries (PIs) are one of the most commonly encountered types of chronic wounds [
1,
2]. A PI is the localised damage caused by persistent or severe pressure with contributions from shear and friction forces, which usually occurs to the skin and underlying soft tissue over a bony prominence or under medical or other devices [
3,
4]. Hospital-acquired PIs (HAPIs) are globally considered “never events” [
5,
6], for being largely preventable and reducible in their severity by using a multifaceted approach [
7,
8]. Of all health conditions, PI currently ranks among the highest in terms of cost, mortality and morbidity rates and prolonged hospitalisation [
3,
6,
9,
10].
Data show that PIs can develop within a period of 1 to 6 h [
11]. The prompt and accurate identification of at-risk individuals is therefore paramount so that preventive measures can be implemented [
6,
12]. The Braden Risk Assessment Tool [
13] is one of the suggested validated tools for assessing PI risk among adult populations [
6]. Risk factors for developing PIs include advanced age, spinal cord injury, decreased sensory perception, unfavourable skin microclimate, faecal and urinary incontinence, poor nutritional status, limited activity and impaired mobility and increased friction and shear forces [
7,
12,
14,
15].
Accurate staging of PIs is essential for appropriate assessment, management and prevention [
4,
10,
15]. The six-category staging system adopted by the National Pressure Ulcer Advisory Panel (NPUAP) in conjunction with the European Pressure Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) is widely used [
4]. Stage 1 is characterised by mild to non-blanchable erythema, which develops into severe tissue loss and exposure of underlying structures (Stage 4). The presence of slough or eschar can hinder accurate staging (unstageable PI), and deep discolouration indicates damage at deeper tissue levels (deep-tissue PI).
The prevalence of PIs is a widely used clinical indicator for the standard of care, and has been shown to have important implications for basic nursing, patient safety and quality outcomes [
6,
10,
16]. A recent systematic review and meta-analysis reported a global total PI prevalence—in hospitals—of 12.8% (95% CI: 11.8–13.9) and a global HAPIs prevalence of 8.4% (95% CI: 7.6–9.3) [
17].
Historically, preventing PIs has been a significant nursing challenge [
18‐
20]. Nurses are the principal implementers of PI-prevention strategies and measures [
6,
20,
21]. However, many clinicians and managers believe that PI development is a failure of the entire healthcare system rather than suboptimal nursing care [
6,
21,
22].
The significance of PI prevalence, nurses’ knowledge, and attitudes towards PI prevention in effective management cannot be overstated. However, a research gap on this topic exists in Kuwait. Thus, the Quality and Accreditation Directorate at the Ministry of Health in Kuwait launched a national research project with the aim of determining the prevalence rate of PIs and prevention strategies implemented in hospitals, and to examine the knowledge and attitude of nurses towards preventing PIs in hospitalised patients. This research is expected to contribute invaluable insights to the field and enhance PI prevention practices in healthcare settings in Kuwait.
Given the size of the research datasets, this article focuses on the prevalence of PIs and preventive measures. Subsequent articles will report on the assessment of nurses’ knowledge and their attitudes towards PI prevention, and explore the relationship of these two aspects with current PI prevention practices and PI prevalence. Here, we evaluate the extent of PIs on the medical wards of the public general hospitals in Kuwait.
The aim of this study was to investigate the prevalence of PIs and preventive measures on the medical wards of the public general hospitals in Kuwait. Our objectives were to identify the characteristics of patients with PIs, the characteristics and prevalence rates of PIs and the characteristics of the implemented PI preventive measures. We also sought to determine whether there were any differences between the studied hospitals regarding PI-diagnosed patients, PI characteristics and prevalence rates, and the implemented PI preventive measures. Finally, we identified the predictors of the prevalence rate of PIs.
Discussion
While the results addressed the study objectives satisfactorily, the findings opened our eyes to some aspects that warrant further discussion. Firstly, the mean prevalence of PIs in Kuwait is higher than the global rate [
17] and shows more variation. Interestingly, the HAPI prevalence in Kuwait is lower than the global rate but still shows more variation [
17]. However, this finding should be interpreted with caution as we are comparing our national rate; which was collected on the medical wards; with the global rate of all wards. What supports this observation is that another recent systematic review and meta-analysis reported a PI prevalence rate of 4.1% (95% CI: 1.3–9.5) on the medical wards [
29]. Unfortunately, the study did not indicate whether this rate was for all PIs or the HAPIs only. To conclude, these findings necessitate not only a review of the strategies for preventing and managing PIs nationally, but also to standardise practices across all hospitals. However, further evidence is required before we accept that the significant statistical difference between hospitals is solely due to the variation in their preventive strategies and practices.
The literature has highlighted the role of various intrinsic and extrinsic risk factors in developing PIs [
30‐
34]. Hospitals have many differences in factors that can impact PI prevalence, such as catchment area populations, nationality, age, and number of available beds. Some of these factors might be the cause of what some articles refer to as “unavoidable PIs” [
34]. Although determining the extent of unavoidable PIs was beyond the scope of this research, it is useful to keep this concept in mind while addressing the subject of PIs in general. In practical terms, what concerns us in this research is to determine the resources required to overcome non-modifiable factors [
32,
35] such as the increase in the number of elderly people or the nationality of patients. Such factors might make re-zoning health regions to control demand, or increasing the number of beds or qualified medical staff to increase capacity, plausible considerations.
Although obesity is one of the principal risk factors for PI [
15,
25,
29,
36], it is striking that weight and height—or preferably both, expressed as body mass index (BMI)—were not among the data that is regularly recorded for all patients. A similar national study [
37] reported a comparable percentage of patients with PIs who were categorised as underweight (7.1%). On the other hand, the percentages of patients with PIs in normal, overweight and obese groups were significantly different (39.1%, 44.5% and 9.3% respectively) [
37]. One cannot make an inference that the differences would stay the same if BMI had been documented in this study for all patients with PIs. Yet, obesity is one of the most important public health concerns In Kuwait [
38]. Also, one should not overlook diabetes [
39] and hypertension [
40], which are both risk factors [
15,
29]. If we add these concerns to the ageing population [
41], the need for a national public health strategy for controlling the alarming prevalence of obesity and diabetes becomes extremely urgent.
We must not ignore that the prevalence of PIs acquired solely in the community was the largest. In fact, the mean national prevalence of CAPIs is significantly higher than the rate reported by Corbett et al. (7.4%) [
22]. This supports our call for developing a national public health strategy. Such a strategy is expected to provide comprehensive home care programmes for the elderly, and to train medical staff and families to prevent, identify and manage PIs.
It is worth considering establishing nursing homes or other long-term care institutions, especially because two-fifths of PIs that occurred in the hospital developed after one month. Whether there was a medical reason (PI or otherwise) for patients to remain in hospital, or because no other appropriate level of care exists, the length of their stays is not commensurate with the acute care that the general public hospitals are supposed to provide. We acknowledge that providing other care institutions might not reduce the number of PIs at national level, but rather transfer some of them from public hospitals to other facilities. Such provision would allow the performance of hospitals in Kuwait to be compared against international standards.
We also noted that more than a third of the PIs were active beyond 3 months. This requires the reasons for the non-response to treatment to be investigated and the current treatment practices to be evaluated. It might be wise to utilise the expertise of wound care specialists, or train nurses on managing PIs that do not respond to treatment.
In stark contrast to the other hospitals, only hospital 4 recorded a majority of PIs related to the use of medical devices (62.1%). This finding warrants particular investigation, especially the contribution of nursing knowledge and attitude, as they are the main care player in PI prevention [
42]. It is striking that this hospital had the third-lowest prevalence of PI (13.7%). It is also the only one of the seven hospitals where HAPIs accounted for the larger percentage (89.7%) of the hospital-recorded PIs. However, the last note is not surprising as medical devices are used more in hospitals than at home.
Braden score—another relevant piece of information—was not routinely recorded for all patients in the study. Such practice was reported in the literature. In an observational study conducted on medical wards, Latimer et al. reported that 71.5% of the sample (
n = 165) in one of the two studied hospitals had not been assessed on admission for risk of PI development [
43]. Although hospitals in the current study showed differences between Braden scores and their documentation, the analysis did not indicate any correlation between Braden score and PI prevalence. Based on evidence from two studies, Moore and Patton concluded that they were “
uncertain whether risk assessment using the Braden tool makes any difference to pressure ulcer incidence, compared with training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone” [
44]. Our findings support their conclusion and raise an important question about the value of the overall Braden score; other literature has also questioned its predictive ability and proposed the use of Braden subscales [
35,
45,
46].
By contrast, nurses are required to use a form to assess all bedridden patients upon their admission; this is aimed at preventing and evaluating PIs. This was reported in all hospitals (except hospital 4) with a variant compliance rate. Apart from the demographic data and mobility status, the form does not include the items of the Braden tool. Indeed, the form does not use any scoring system. Instead, it contains the following items: continence versus incontinence, the presence of Foley’s catheter, level of consciousness, mental status, and PI (if any) site, size and colour. The main purpose here is to have a baseline assessment of the PI for follow up. Because this preventive measure is the only one that was included in the linear regression analysis for its statistical significance, we can infer that clinically assessing PIs on admission using any tool—regardless of the score—reduces the prevalence of HAPIs.
In contrast to two systematic reviews [
17,
29], at our hospitals, stage 2 had the largest percentage of the worst-stage PI groups, not stage 1. This was true of the national distribution and at five of the seven hospitals, regardless of whether the acquisition was in the community or the hospital. This finding raises a significant concern regarding the efficiency and efficacy of the current practices used for early identification and prevention of PIs, especially because almost half of the patients received three or four preventive measures. Notably, the study did not investigate the practices of managing PIs already developed. Unlike for the PI stage, our results align with other studies [
12,
14,
17,
29], which reported sacrum, buttocks and heels as the most common locations for PI development.
Many interventions are designed to prevent PIs by reducing friction and shear. These include support surfaces (e.g., mattresses, integrated bed systems, overlays, cushions), repositioning, nutritional supplementation, skin care (e.g., dressings, incontinence management) and topical creams [
47]. Although almost half of the patients with PIs were given three to four preventive measures, only three patients received an air mattress. Such a simple provision should not be an issue for a high-income country like Kuwait. In Australia, 24.7% of the study sample (
n = 799) received an air mattress [
48]. The percentage is even higher in the “at PI risk” groups (29.1%). Notably, the study reported PI prevention in routine clinical practice.
Another preventive measure that was expected to be provided to all patients was repositioning (depending on the patient’s condition). Chaboyer et al. [
48] found that the repositioning schedule was implemented in 67.4% of the ”at PI risk” groups; the same percentage of this study. This intervention primarily depends on sufficient staffing and appropriate workload assignment. Like the rest of the world, Kuwait suffers from a shortage of nurses [
41]. The situation is worsened by the fact that the approved staffing ratios for nurses, devised in 2013 [
49], are no longer in line with the responsibilities given to nurses that have increased since. Given the increasing number of bedridden and long-staying patients, staffing ratios should be urgently updated and take workload assignment into account.
Strengths and limitations
This study has several strengths. It is the first nationwide study in Kuwait or the region to assess PI prevalence in public hospitals. The cross-sectional design enabled different variables in the population sample to be measured at a single point in time for gathering accurate data that are less prone to the potential bias of case series and case reports [
50].
However, some limitations exist. The study is designed to determine relationships between variables, not to imply causality between them. In addition, it was not feasible to collect data on the whole sample population (n = 1,186). This prevented us from comparing study variables between the PI group and the PI-free group. Furthermore, data were extracted from patients’ files. The validity of such data is subject to the accuracy of the nurses in documenting for the files.
Practice and research implications
The overall objective of this study was to examine the prevalence of PIs and preventive measures in Kuwait’s general public hospitals. In addition to the previously mentioned strategic initiatives, such as the re-zoning of health regions or providing other levels of care, some changes in practice must be introduced.
There is an immediate need to review and standardise the current measures for preventing and treating PIs. Also, the daily assessment of PIs should include a reassessment of the risk of developing a new PI. In addition, nutritional assessment is currently not undertaken. The patient might require nutritional assessment and support even if they are not underweight. Prolonged confinement to bed results in muscle wasting and a negative nitrogen balance [
51], which affects skin integrity and impairs healing processes. We also call for an increase in the number of nurses or providing nursing assistants to carry out duties that do not require nursing competencies, such as repositioning patients.
We call on researchers to study the socio-economic impact of PI on individuals and the healthcare system. There is a gap in the literature regarding PI prevalence and preventive practices in other hospital wards or at tertiary or private hospitals in Kuwait. Another avenue for research is to examine the current practices for treating PIs. Finally, we recommend the use of other research approaches and study designs—such as qualitative approaches and survival analysis—to overcome some of the study limitations and better understand the topic.
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