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

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Journal of Nursing, 117(12), 36–45. https://doi.org/10.1097/01.NAJ.0000527460.93222.31

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Pressure Ulcer Advisory Panel White Paper. Advances in Skin & Wound Care.

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