Research unlocks the heart of cardiac patient pressure injury
Nursing Research and Practice Development Centre Nurse Research Assistant Sarah Schnaak
Pressure injuries remain a persistent and often underestimated complication in adult cardiac patients, causing physical and emotional distress and increasing the patient’s length of stay in hospital.
Following surgery, cardiac patients can be immobile, hemodynamically unstable and dependent on complex medical devices, all of which increase their vulnerability to skin and tissue damage. Reduced cardiac output can also impair tissue perfusion, limiting oxygen and nutrient delivery to the tissues and skin.
Necessary devices such as artificial ventilation, circulation support, monitoring leads and compression stockings can also create additional pressure points. As a result, even short periods of unrelieved pressure can lead to rapid tissue breakdown.
The Prince Charles Hospital (TPCH) Nursing Research and Practice Development Centre Nurse Research Assistant Sarah Schnaak said pressure injuries (PI) for adult cardiac patients continued to be a patient safety concern despite implementation of evidence-based preventative strategies.
“We know that cardiac patients undergoing surgery are at higher risk of PI occurrence due to a multitude of risk factors,” Ms Schnaak said.
However, few studies have looked at the incidence of PI that develop within two days of discharge from the operating theatre and the specific risk factors for adult patients undergoing cardiac surgery during the perioperative phase.
The perioperative phase for this study encompasses the surgical experience spanning from preoperative admission to hospital through to discharge from the intensive care unit.
At TPCH, approximately 1,000 episodes of cardiac surgery are carried out each year.
“By identifying the incidence and characteristics of perioperative pressure injury in TPCH adult cardiac surgical patients, the research will provide insight into the scope of the problem,” Ms Schnaak said.
From current studies, pre-operative risk factors thought to contribute to PI included patient comorbidities such as high or low blood pressure, diabetes and smoking.
Total time in the operating room, use of balloon pumps, time on extracorporeal support, lower central venous pressure and heart rate, were all considered intraoperative factors with admission to ICU.
The use of medical devices and immobility were significant in the postoperative stage.
Ms Schnaak started by retrieving three years of retrospective patient data from three hospital databases for adult patients who had cardiac surgery between 2020 and 2022.
From this, a subset of patients that developed a PI within two days of discharge from the operating theatre were identified. All data were cross-checked with medical records if necessary. Comparisons of risk factors were made between adult cardiac surgical patients who developed a PI and those who did not.
She found the cumulative incidence rate of the hospital-acquired pressure injuries (HAPI) in cardiac patients was 1.8 per cent. Of these cases, 82 per cent were men with 55 per cent being an urgent or emergency case. More than 98 per cent of these patients were admitted to ICU post-operatively, with an average length of stay of five days.
Ms Schnaak also found that from a total of 82 HAPIs, medical device related PIs (MDRPIs) accounted for 68 per cent of PIs with 82 per cent of these related to the Endotracheal tube (ETT) including tube, tapes and attachment devices.
In addition, suspected deep tissue injuries (SDTI) which are considered as a hospital acquired complication (HAC), accounted for 19.5 per cent of HAPIs, with the most common sites being the sacrococcygeal area, near the base of the spine.
These preliminary findings indicate that whilst the cumulative incidence rate is low, the adult cardiac surgical patient may be particularly vulnerable to mucosal injury from medical devices as well as SDTIs.
“Further data analysis is in progress to pinpoint specific risk factors for patients who developed a PI compared to those who did not, to better inform clinical practice guidelines in pressure injury prevention for the adult cardiac surgical patient,” Ms Schnaak said.
“New knowledge gained providing could inform and facilitate the implementation of targeted preventive strategies.
“The final stage will focus on uncovering unique PI risk factors that impact cardiac surgical patients.
“We will finalise our data analysis for publication with the goal to guide clinical practice for preventing PIs during cardiac surgery and ultimately reducing patient harm.
“Having the opportunity to carry out this research now gives us the data to both improve clinical practice and look at future projects.”
Sarah’s work was made possible a New Investigator Grant by The Prince Charles Hospital Foundation.