Biophysical detection of skin changes to cue pressure injury prevention in nursing homes

Abstract
Pressure injuries (PrIs), commonly located over bony prominences, are local areas of damage to the skin and
underlying soft tissue caused by pressure and shear forces. These painful, dangerous, costly, and preventable
injuries in nursing home (NH) residents are associated with reduced quality of life and mortality. This
embedded pragmatic stepped wedge cluster clinical trial, using a mixed-methods approach for all residents in
8 NHs, will examine use of subepidermal moisture (SEM) assessment results as a cue for nursing staff to
initiate PrI prevention. SEM assessment, a biophysical measure that senses changes in skin characteristics,
detects early pressure damage by identifying subclinical signs of PrI. SEM use is an innovative addition to
current PrI prevention care that is currently initiated upon a positive risk assessment and/or a visual inspection
of skin discoloration. Significant damage exists by the time erythema or purple skin is observed. Lag time
between pressure-induced tissue damage and visual detection of skin discoloration delays nursing actions to
prevent PrIs. Discoloration is more difficult to discern in persons with dark skin tones, making skin damage
detection more challenging for residents from minority or under-represented racial/ethnic groups than those
with lighter skin tones; thus, producing a health disparity. The study will incorporate SEM assessment into PrI
prevention standard-of-care and conduct the intervention over a 9-month period. The study aims are to: 1)
determine if early pressure damage detected by SEM assessment at time of visual skin observation of NH
resident sacral and heel areas is effective in cueing initiation of NH standard PrI prevention; 2) examine the
association between NH standard PrI prevention and SEM assessment and NH residents’ characteristics (age,
gender, risk, skin tone, race, ethnicity, BMI, cognitive status) and their interactions on individual NH residents
with regard to initiation of NH standard PrI prevention and PrI occurrence; and, 3) explore if SEM usability, NH,
and nursing staff characteristics influence the adoption and assimilation of early PrI detection and subsequent
PrI prevention practices. Current NH PrI prevention protocols and periodic safety and care checks will be
performed. Sample will be comprised of all residents at intervention start and those newly admitted during the
9-month intervention period. An intention to treat approach will be used for quantitative analyses with resident
data accrued throughout the intervention period included in analyses. Cueing effectiveness will be determined
by evaluating the initiation of PrI prevention strategies in relation to SEM values and the development of PrI
during the intervention. Mixed effects regression models for clustered/repeated measures will use electronic
health record data and SEM assessment values modeled to predict initiation of PrI prevention actions.
Qualitative analyses will be applied to focus group data with comparison to cueing effectiveness findings.
Study results will advance knowledge about clinically assessed PrI risk-level and contribute to future redesign
of preventive nursing practices and refinement of PrI prevention guidelines.

Grant Number: 5R01NR020487-04
NIH Institute/Center: NIH
Principal Investigator: Barbara Bates-Jensen