Characteristics of Critically Ill Adults with Unavoidable Sacrococcygeal Hospital Acquired Pressure Injuries (HAPI): A Case Control Study

Significance: While hospital acquired pressure injuries (HAPI) are generally considered preventable, experts agree some are unavoidable. Unavoidable HAPI can occur due to hypoperfusion secondary to organ dysfunction or failure, despite aggressive HAPI prevention.^1,2 Research of unavoidable HAPI is limited and most studies lack HAPI diagnosis by a Certified Wound Care Nurse (CWCN). The purpose of this case control study is to compare clinical characteristics of ICU patients with and without unavoidable sacrococcygeal HAPI.  

Methods: Data collected 2014 to 2016, during monthly prevalence surveys, were reviewed to identify cases. Inclusion criteria included patients ≥18 years old, admitted to ICU >24 hours, and HAPI diagnosed by CWCN. Health records were reviewed to confirm unavoidable HAPI using the Pressure Ulcer Prevention Inventory.³ Unavoidable cases were matched to controls by age, gender and race. Differences between groups were analyzed using Wilcoxon rank sum, chi-square and t-test. Statistical significance was set at p ≤.01. Variables included hospital length of stay (LOS), disposition (discharged/ expired), sepsis diagnosis, Braden Scale and sequential organ failure assessment (SOFA) scores. Braden and SOFA scores were examined at admission, 7 days before event (HAPI occurrence or last prevalence date), 1 day before event and discharge.

Results: 34 unavoidable sacrococcygeal HAPI cases were identified. Patients with unavoidable HAPI had significantly longer LOS, proportionally more sepsis diagnoses and expiration during hospitalization. There was no difference between total Braden and SOFA scores at admit. Patients with unavoidable HAPI had significantly greater risk per Braden and significantly higher SOFA scores (more severe organ failure) at 7 and 1 days before HAPI and discharge/expiration.

Conclusions: Unavoidable HAPI is associated with poor outcomes including prolonged LOS and increased mortality. More severe organ failure was noted one day before unavoidable HAPI occurrence. These findings can inform public policy and penalties for HAPI occurrence. Future prospective research is warranted.