Table 3.
Summary of Evidence for Risk Factor Domains and Subdomains
| Variable | Studies With Variable Significant in Multivariate Model Study Quality (Study Authors) Variable: Odds Ratio (95% Confidence Interval) | Studies With Variable Not Significant in Multivariate Model Study Quality (Study Authors) Variable |
|---|---|---|
| Domain 1: Mechanical Boundary Conditions | ||
| Body size | – | MQS (Manzano et al.21) Body weight LQS (Compton et al.28) Body weight and height |
| Friction and shear | HQS (Cox20) Friction/shear: 5.715 (1.423–22.95) | – |
| Emergent vs. scheduled admission | LQS (Kaitani et al.23) Scheduled admission: 0.04 (0–0.47) VLQS (Eachempati et al.31) Emergent admission: 36 (0.2290–0.7694) |
HQS (O’Brien et al.19) Emergent admission MQS (Manzano et al.21) Type of admission (medical vs. surgical) LQS (Tayyib et al.25) Emergent admission LQS (Kaitani et al.23) Admission type |
| Domain 1 Subdomain: Immobility | ||
| Mental/neurologic status | – | MQS (Nijs et al.22) GCS: opens eyes MQS (Nijs et al.22) GCS: movement, localizes pain MQS (Nijs et al.22) GCS: movement, follows commands LQS (Compton et al.28) Minimum GCS LQS (Compton et al.28) Maximum GCS LQS (Sayar et al.24) Consciousness LQS (Sayar et al.24) Cooperation LQS (Theaker et al.26) Pain |
| Mobility/activity | HQS (Cox20) Mobility: 0.439 (0.21–0.95) LQS (Sayar et al.24) Activity level: 0.3 (0.2–0.7) |
– |
| Sensory perception | – | HQS (Cox20) Sensory perception |
| Surgical factors | HQS (O’Brien et al.19) Noncardiac surgery: 1.84 (1.31–2.59) | LQS (Tayyib et al.25) Operation time |
| Turning/repositioning and surface | HQS (Suriadi et al.18) Interface pressure: 2.2 (1.6–2.9) MQS (Nijs et al.22) “Adequate prevention”: 6.0 (1.9–18.6) MQS (Nijs et al.22) Frequency of turning six or more times daily or alternating mattress: 30.2 (12.2–74.8) MQS (Nijs et al.22) “Turning”: 6.7 (2.7–16.4) MQS (Nijs et al.22) Sitting in chair: 0.1 (0.0–0.3) LQS (Tayyib et al.25) Infrequent repositioning: 2.96 (1.23–7.153) LQS (Kaitani et al.23) Frequency of turning: 0.45 (0.21–.0.97) |
HQS (Slowikowski & Funk4) Not repositioned LQS (Theaker et al.26) Too unstable to turn |
| Domain 2: Susceptibility and Tolerance of the Individual | ||
| Age | HQS (Cox20) Age: 1.033 (1.003–1.064) HQS (O’Brien et al.19) Age: 1.02 (1.01–1.03) HQS (Slowikowski & Funk4) Age≥70 years: 2.14 (1.27–3.62) MQS (Frankel et al.2) Age: 2.9 (1.2–7.1) LQS (Tayyib et al.25) Age: 1.254 (1.054–1.492) VLQS (Eachempati et al.31) Age: 1.08 (0.0026–0.0131) |
MQS (Manzano et al.21) Age |
| Body temperature | HQS (Suriadi et al.18) Body temperature: 2.0 (1.7–2.5) MQS (Nijs et al.22) Body temperature≥38.5: 0.2 (0.2–0.9) |
LQS (Compton et al.28) Maximum body temperature |
| Diagnosis (excepting diagnosis related to oxygenation and perfusion, included below under Subdomain: Poor Perfusion) | HQS (O’Brien et al.19) History of renal failure: 1.75 (1.27–2.39) LQS (Frankel et al.2) Spinal cord injury: 16.8 (1.5–182) LQS (Yepes et al.30) Presence of infection: 4.39 (6.92–18.25) |
HQS (O’Brien et al.19) History of liver disease MQS (Manzano et al.21) Multiple organ failure MQS (Nijs et al.22) Gastrointestinal diagnosis LQS (Tayyib et al.25) History of kidney disease |
| Laboratory values (excepting values related to oxygenation and perfusion, included below under Subdomain: Poor Perfusion) | LQS (Frankel et al.2) Creatinine: 3.7 (1.2–9.2) LQS (Theaker et al.26) Anemia: 2.81 (1.24–6.34) |
HQS (Cox & Roche17) Severe anemia LQS (Compton et al.26) Maximum serum potassium LQS (Compton et al.28) Maximum creatinine LQS (Compton et al.28) Maximum blood glucose LQS (Compton et al.28) Maximum c-reactive protein LQS (Compton et al.28) Minimum thromboplastin time LQS (Compton et al.28) Maximum serum bilirubin LQS (Ulker Efteli & Yapucu Gunes27) Hemoglobin LQS (Ulker Efteli & Yapucu Gunes27) Blood glucose LQS (Sayar et al.24) C-reactive protein LQS (Theaker et al.26) Coagulopathy |
| Length of stay | HQS (Cox20) Length of ICU stay: 1.008 (1.005–1.011) LQS (Sayar et al.24) Length of stay: 1.2 (1.1–1.3) LQS (Tayyib et al.25) Longer ICU stay: 1.831 (1.014–3.309) LQS (Yepes et al.30) Length of stay: 1.13 (1.06–1.22) LQS (Theaker et al.26) Length of stay > 3 days: 2.76 (1.08–7.05) VLQS (Cremasco et al.1) Length of ICU stay: 1.120 (1.943–1.202) VLQS (Eachempati et al.31) Days in bed: 1.05 (−0.0013–0.0156) |
HQS (Cox & Roche17) Hospital length of stay HQS (Cox & Roche17) Length of stay before ICU admission HQS (Cox & Roche17) ICU length of stay MQS (Manzano et al.21) ICU length of stay MQS (Manzano et al.21) Pre-ICU hospital stay LQS (Compton et al.28) Duration of ICU stay |
| Medication (excepting vasopressors) and treatments | MQS (Nijs et al.22) Sedative use: 0.3 (0.1–0.7) MQS (Nijs et al.22) Dialysis: 3.8 (1.0–3.9) |
HQS (O’Brien et al.19) Current corticosteroid use HQS (Slowikowski & Funk4) Orthotics HQS (Slowikowski & Funk4) Hemodialysis MQS (Nijs et al.22) Physical fixation MQS (Nijs et al.22) Major analgesics MQS (Nijs et al.22) “Floating heels” LQS (Compton et al.28) Sedation LQS (Compton et al.28) Insulin therapy LQS (Theaker et al.26) Current corticosteroid use |
| Nutrition and laboratory values related to nutrition status |
LQS (Ulker Efteli & Yapucu Gunes27) Lower serum albumin level: 11.6 (1.92–70.4) VLQS (Eachempati et al.31) Days without any nutrition 0.51 (−0.1095–−0.0334) |
HQS (Cox20) Nutrition LQS (Compton et al.28) Parenteral nutrition LQS (Kaitani et al.23) Nutrition LQS (Theaker et al.26) Serum albumin LQS (Theaker et al.26) Reduced nutritional intake |
| Severity of illness/health status | HQS (Cox & Roche17) Cardiac arrest: 3.894 (0.998–15.118) HQS (O’Brien et al.19) ASA class 4 or 5: 1.63 (1.19–2.23) MQS (Manzano et al.21) Day 1 respiratory SOFA: 1.56 (1.026–2.360) MQS (Manzano et al.21) Day 4 cardiovascular SOFA: 1.33 (1.066–1.664) LQS (Yepes et al.30) APACHE II: 1.06 (1.0–1.12) LQS (Theaker et al.26) APACHE II> 13: 2.4 (1.4–7.92) VLQS (Cremasco et al.1) SAPSII score: 1.058 (1.004–1.114) |
HQS (Cox20) APACHE HQS (Cox & Roche17) APACHE II HQS (Cox & Roche17) Died in ICU MQS (Manzano et al.21) Hospital mortality MQS (Nijs et al.22) APACHE II LQS (Ulker Efteli & Yapucu Gunes27) APACHE II LQS (Compton et al.28) ICU mortality LQS (Compton et al.28) TISS LQS (Kaitani et al.23) APACHE II LQS (Theaker et al.26) Peripheral vascular disease VLQS (Eachempati et al.31) MODS VLQS (Eachempati et al.31) APACHE III |
| Domain 2 Subdomain: Poor Perfusion Including Factors That Affect Oxygenation and Perfusion Status/Delivery of Oxygen to the Tissues | ||
| Blood pressure | HQS (Cox & Roche17) Hours of MAP less than 60 mm HG while on vasopressors: 1.096 (1.020–1.178) |
HQS (Cox20) Mean arterial pressure HQS (Cox20) Systolic blood pressure HQS (Cox20) Diastolic blood pressure |
| Diagnosis related to oxygenation and/or perfusion (also included in global diagnosis, above) | HQS (Cox20) Cardiovascular disease: 2.952 (1.3–6.4) HQS (Cox & Roche17) Cardiac diagnosis at admission: 0.035 (0.002–0.764) HQS (O’Brien et al.19) History of heart failure: 1.78 (1.27–2.49) HQS (Slowikowski & Funk4) Diabetes: 1.93 (1.11–3.35) HQS (Suriadi et al.18) Cigarette smoking: 1.6 (1.1–2.5) MQS (Nijs et al.22) Vascular disease: 4.5 (2.0–10.2) LQS (Frankel et al.2) Diabetes: 2.7 (1.1–6.4) |
HQS (O’Brien et al.19) History of diabetes MQS (Manzano et al.21) Septic shock MQS (Manzano et al.21) Acute respiratory distress syndrome LQS (Frankel et al.2) Vascular disease LQS (Compton et al.28) Sepsis LQS (Tayyib et al.25) History of cardiovascular disease LQS (Theaker et al.26) Diabetes LQS (Theaker et al.26) History of smoking |
| Heart rate and monitoring | LQS (Compton et al.28) Maximum heart rate LQS (Compton et al.28) Invasive monitoring |
|
| Oxygenation/ventilation | HQS (Cox & Roche17) mechanical ventilation longer than 72 hours: 23.604 (6.427–86.668) HQS (O’Brien et al.19) existing airway: 5.28 (3.63–7.67) MQS (Manzano et al.21) length of mechanical ventilation: 1.042 (1.005–1.080) |
HQS (Slowikowski & Funk4) Ventilator support MQS (Manzano et al.21) Pa02/Fi02 ratio on Day 1 MQS (Nijs et al.22) Mechanical ventilation LQS (Compton et al.28) Minimum PaCO2 LQS (Compton et al.28) Minimum arterial pH LQS (Compton et al.28) Mechanical ventilation LQS (Compton et al.28) Cyanosis LQS (Tayyib et al.25) Mechanical ventilation |
| Vasopressor | HQS (Cox20) Norepinephrine: 1.017 (1.001–1.033) HQS (Cox & Roche17) Vasopressin infusion: 4.816 (1.666–13.925) MQS (Nijs et al.22) Dopamine<5 mcg/kg/min: 6.1 (1.9–19.5) LQS (Theaker et al.26) Norepinephrine infusion: 8.11 (3.64–18) |
LQS (Compton et al.28) Vasopressor therapy LQS (Frankel et al.2) Vasopressor therapy LQS (Theaker et al.26) Dopamine LQS (Theaker et al.26) Epinephrine LQS (Theaker et al.26) Norepinephrine |
| Domain 2 Subdomain: Skin/Pressure Injury Status Including Factors That Affect Skin and Pressure Injury Status |
||
| Moisture | LQS (Compton et al.28) Moist skin: 2.4 (NR) | LQS (Theaker et al.26) Moisture |
| Skin/external skin factors/PI status | LQS (Compton et al.28) Edematous skin: 2.2 (NR) LQS (Compton et al.28) Centralized circulation: 2.4 (NR) LQS (Compton et al.28) Mottled skin: 2.0 (NR) LQS (Compton et al.28) Reddened skin: 2.3, (NR) LQS (Theaker et al.26) Fecal incontinence: 3.27 (1.32–8.3) |
HQS (Cox & Roche17) Peripheral necrosis in patients receiving vasopressors HQS (Slowikowski & Funk4) Edema MQS (Nijs et al.22) Pitting edema LQS (Compton et al.28) Livid skin LQS (Compton et al.28) Hyperemic skin LQS (Kaitani et al.23) Edema LQS (Theaker et al.26) Edema |
| Other Factors Not Included In Domains 1 or 2 | ||
| Gender | LQS (Ulker Efteli & Yapucu Gunes27) Female gender:0.15 (0.03–0.71) LQS (Compton et al.28) Male gender: 1.8 (NR) VLQS (Cremasco et al.1) Male gender: 5.6 (1.42–22.09) |
LQS (Kaitani et al.23) gender G |
| Risk-assessment scales | HQS (Slowikowski & Funk4) Braden Scale score: 1.3 (1.15–1.47) LQS (Fife et al.29) Braden Scale score: NR (NR) VLQS (Eachempati et al.31) CURS Day 8: 1.45 (−0.0048–−0.0833) |
HQS (Cox20) Braden Scale total HQS (Cox & Roche17) Braden Scale at hospital admission HQS (Cox & Roche17) Braden Scale at ICU admission LQS (Compton et al.28) Waterlow score LQS (Tayyib et al.25) Braden Scale score |
| Other factors | MQS (Manzano et al.21) Winter admission: 4.6 (1.99–10.59) VLQS (Cremasco et al.1) NAS score: 0.916 (0.855–0.980) |
– |
Adapted from Coleman et al.9
HQS = high-quality study
MQS = moderate-quality study
LQS = low-quality study
VLQS = very-low-quality study
GCS = Glaslow Coma Score
APACHE = Acute Physiology and Chronic Health Evaluation
TISS = Trauma Injury Severity Score
MODS = multiple organ dysfunction syndrome
PA02/FI02 = ratio of arterial oxygen partial pressure to fractional inspired oxygen PaCO2 = carbon dioxide partial pressure
MAP = mean arterial pressure
CURS = Corneil ulcer risk score
NAS = nursing activities score
PI = pressure injury