Improving pressure ulcer care in intensive care units: Evaluating the impact of bundled care and silver nanoparticle dressings

Abstract

BACKGROUND

Pressure ulcer (PU) are prevalent among critically ill trauma patients, posing substantial risks. Bundled care strategies and silver nanoparticle dressings offer potential solutions, yet their combined effectiveness and impact on patient satisfaction remain insufficiently investigated.

AIM

To assess the impact of bundled care along with silver nanoparticle dressing on PUs management and family satisfaction in critically ill trauma patients.

METHODS

A total of 98 critically ill trauma patients with PUs in intensive care unit (ICU) were included in this study. Patients were randomly assigned to either the control group (conventional care with silver nanoparticle dressing, n = 49) or the intervention group (bundled care with silver nanoparticle dressing, n = 49). The PU Scale for Healing (PUSH) tool was used to monitor changes in status of pressure injuries over time. Assessments were conducted at various time points: Baseline (day 0) and subsequent assessments on day 3, day 6, day 9, and day 12. Family satisfaction was assessed using the Family Satisfaction ICU 24 questionnaire.

RESULTS

No significant differences in baseline characteristics were observed between the two groups. In the intervention group, there were significant reductions in total PUSH scores over the assessment period. Specifically, surface area, exudate, and tissue type parameters all showed significant improvements compared to the control group. Family satisfaction with care and decision-making was notably higher in the intervention group. Overall family satisfaction was significantly better in the intervention group.

CONCLUSION

Bundled care in combination with silver nanoparticle dressings effectively alleviated PUs and enhances family satisfaction in critically ill trauma patients. This approach holds promise for improving PUs management in the ICU, benefiting both patients and their families.

Key Words: Pressure ulcers; Silver nanoparticle dressings; Bundled care; Pressure ulcer scale for healing tool; Family satisfaction

Core Tip: The findings indicate significant reductions in total pressure ulcer scale for healing scores in the intervention group, with notable improvements in surface area, exudate, and tissue type parameters compared to the control group. Moreover, family satisfaction with care and decision-making was substantially higher in the intervention group, demonstrating the positive impact of bundled care on both patient outcomes and family experience in the intensive care unit setting.

INTRODUCTION

Pressure ulcer (PU) result from the application of pressure, friction, and/or shear to the skin and underlying tissues, often exacerbated by moisture, which impairs blood supply and causes injury to both the skin and underlying tissues[1]. PUs constituted a notable complication during prolonged hospital stays across diverse healthcare environments. Their incidence typically remains below 2%, but it can vary significantly, ranging from 1% to as high as 56% within intensive care units (ICU), primarily due to the patients” limited ability to change positions independently, with the optimal incidence rate falling within 1% to 5%[2]. Critically ill patients with PU face heightened morbidity and mortality, prolonged intensive care requirements, increased hospitalization costs, a role in infection transmission within clinical settings, and elevated patient morbidity and mortality rates, underscoring the importance of effective PU treatments[2,3].

Proper dressing selection is crucial in treating PUs, significantly affecting the healing process[4]. An ideal dressing should maintain a moist wound environment, provide optimal temperature, facilitate oxygen and CO₂ exchange, allow for ulcer visibility, possess high absorption capacity, cause minimal pain during replacement, be easy to apply, and be cost-effective for patients[5]. Nanotechnology has already been widely applied in clinical medicine, such as in the immunotherapy of tumors and the treatment of inflammatory diseases[6]. Modern dressings, like silver nanoparticle dressings, offer advanced features compared to conventional options[6]. Initially used for burns, silver nanoparticle dressings have shown promise in PUs treatment, with the potential for further research and application[7].

A care bundle is a concise set of evidence-based interventions tailored for a specific patient group and care environment, with the collective implementation of these interventions leading to significantly improved outcomes compared to their individual use[8]. In recent years, care bundles have been recognized as effective tools in reducing the incidence of PUs[1,9,10]. However, limited research has explored the role of bundled care in patients with PUs.

Therefore, this study seeks to evaluate the impact of bundled care in conjunction with silver nanoparticle dressings on the management of PUs in critically ill trauma patients. Additionally, I aim to assess the influence of this intervention on family satisfaction, recognizing the vital role families play in the care of critically ill patients. The results of this study have the potential to enhance clinical practices, improve the quality of care for critically ill patients, and ultimately lead to better patient outcomes and increased satisfaction.

MATERIALS AND METHODS

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of this hospital. Written informed consent was obtained from all patients, legal guardians, or authorized representatives.

Enrolled subjects

Between August 2022 and August 2023, I enrolled 98 critically ill trauma patients who met specific inclusion criteria. These patients were admitted to the Emergency Department and subsequently transferred to the ICU. Inclusion criteria involved meeting the defined criteria for pressure injuries according to the National PU Advisory Panel and the European PU Advisory Panel. Patients had multiple pressure injuries (two or more) while in the ICU, with no evidence of infection in these injuries and the non-utilization of alternative dressings. Patients were required to have spent at least 24 h in the ICU, and their medical records pertaining to pressure injuries had to be complete with no missing data. Their Braden scores, which range from 6 to 23 (lower scores indicating a higher risk of developing pressure injuries), were also taken into consideration[11]. Patients with a single site of pressure injury were randomly divided into two groups: 46 patients received conventional care alongside silver nanoparticle dressing (control group), and the other 46 patients received bundled care in conjunction with silver nanoparticle dressing (intervention group).

Bundled care

Bundled care necessitates a multidisciplinary approach to ensure that patients receive high-quality wound care (Table 1). It involves close collaboration among physicians, nurses, physical therapists, dietitians, and other specialists for the development and execution of a comprehensive treatment plan. The active participation of patients and their families is crucial for successful treatment. Critical care nurses undergo annual training in pressure injury identification and staging, which includes conducting a thorough skin inspection during each shift and recording relevant information[12]. This encompasses evaluating the skin for inflammation, gentle wound cleansing, and maintaining a moist wound environment with proper dressings. Dietitians closely monitor the nutritional status of patients and design high-protein dietary plans to support wound healing. For patients who can orally consume food, oral nutritional supplements are administered in addition to standard nutrition[13]. Effective pain management and education for patients and families are integral. Continuous monitoring and reassessment of PUs ensure effective tracking of healing progress.

Table 1 Bundled care in the management of pressure ulcers in critically Ill adults in intensive care units.

Bundled care	Contents
1. Multidisciplinary collaboration	Ensure collaboration among healthcare professionals, including physicians, nurses, physical therapists, dietitians, and other specialists, to develop and execute a comprehensive care plan
	Hold regular interdisciplinary meetings to share information, coordinate treatment measures, and provide a unified approach to care
	Nurses conducts a thorough skin inspection during each shift and recording relevant information
2. Assessment	Conduct a thorough pressure ulcer assessment, including a detailed description of the wound's depth, size, shape, edge condition, and characteristics of the wound base
	Evaluate the skin surrounding the wound for signs of inflammation, redness, or swelling
3. Wound cleansing	Use a gentle saline solution or specialized wound cleansing solution to clean the wound with gauze or sterile cotton balls, avoiding the introduction of new bacteria
	Remove necrotic tissue, exudate, and debris to ensure a clean wound surface
4. Maintain moisture	Use the dressing to maintain a moist wound environment, which accelerates healing and supports new tissue growth
	Change the dressing as needed, typically when the dressing changes color from dark green to light green, indicating over 70% of the silver has been released
5. Nutritional support	Dietitians closely monitor the nutritional status of patients and design high-protein dietary plans to support wound healing
	Ensure the patient receives adequate protein and vitamin intake to support wound healing
	Provide oral nutritional supplements or enteral nutrition support through a feeding tube, depending on the patient's oral intake capacity
6. Pain management	Offer effective pain management, including medication, to alleviate wound discomfort
	Use non-pharmacological methods such as heat therapy, cold compresses, or relaxation techniques to reduce discomfort and pain
7. Prevent further deterioration	Ensure regular patient repositioning t least every 2 hours to prevent prolonged pressure on the same area
	Use specialized mattresses, cushions, and care pads to reduce pressure and provide appropriate support
8. Education	Provide comprehensive education to both the patient and family members, including wound monitoring, recognizing signs of infection, and proper wound care methods
	Emphasize the importance of pressure ulcer prevention, including pressure distribution and turning techniques
9. Data monitoring	Continuously monitor wound progress and any changes, documenting observations
	Reassess the pressure ulcer's status regularly to track healing progress

Silver nanoparticle dressings

In addition to the above, the study employed silver nanoparticle dressings, manufactured by AgCoat (China), which were available in various sizes (5 cm × 5 cm and 10 cm × 10 cm) with a silver concentration of 1.7 ppm/cm². The dressing application procedure involved initially cleansing the pressure injury with a saline solution. Subsequently, sterile gauze was used to gently pat dry the saline solution on the pressure injury. The silver nanoparticle dressing was then applied to the pressure injury, ensuring it extended 1 cm beyond the wound edges. Sterile gauze was placed on the pressure injury, and the dressing was secured in position using a simple bandage. As per the manufacturer's guidelines, a change in the dressing's color from dark green to light green indicated that over 70% of its silver had been released, necessitating replacement (typically occurring in about 72 h according to the manufacturer's instructions). Dressings were changed every three days by a nurse with ten years of experience in pressure injury care and dressing.

PU scale for healing tool

The PU scale for healing (PUSH) tool is used to monitor the changes in the status of pressure injuries over time. Assessments are conducted before the application of dressings (day 0), as well as on day 3, day 6, day 9, and day 12. This tool evaluates three wound characteristics, including surface area, the amount of exudate (drainage), and tissue type. Scores are assigned to each parameter, as detailed in Table 2. The total PUSH score, ranging from 0 to 17, provides an overall assessment of the severity of a pressure injury, with higher scores indicating more severe wounds[14].

Table 2 Assigning scores to parameters in the pressure ulcer scale for healing tool.

Parameter	Description	Score
Surface area	Determined by multiplying the greatest length by the greatest width	0-10
	0 cm²	0
	< 0.3 cm²	1
	0.3-0.6 cm²	2
	0.7-1.0 cm²	3
	1.1-2.0 cm²	4
	2.1-3.0 cm²	5
	3.1-4.0 cm²	6
	4.1-8.0 cm²	7
	8.1-12.0 cm²	8
	12.1-24.0 cm²	9
	> 24.0 cm²	10
Exudate (drainage)	Assessed at dressing removal before applying a topical agent	0-3
	None	0
	Light	1
	Moderate	2
	Heavy	3
Tissue type		0-4
Closed/resurfaced	The wound is completely covered with epithelium/new skin	0
Epithelial tissue	New pink or shiny tissue/skin growing in from the edges or as islands on the ulcer surface (for superficial ulcers)	1
Granulation tissue	Pink or beefy red tissue with a shiny, moist, granular appearance	2
Slough	Yellow or white tissue adhering to the ulcer bed in strings or thick clumps, or is mucinous	3
Necrotic tissue/eschar	Black, brown, or tan tissue adhering firmly to the wound bed or ulcer edges, may be firmer or softer than surrounding skin	4
Total PUSH score	Obtained by summing the scores for the above three parameters	0-17

PUSH: Pressure ulcer scale for healing.

Family satisfaction ICU 24 questionnaires

The Family Satisfaction ICU 24 (FS ICU-24) questionnaire, a reliable and widely used tool, was used to assess family satisfaction on day 12 in ICUs[15]. It comprises 24 items: 14 about care satisfaction, including quality and nurse-family communication frequency, and 10 about decision satisfaction, focusing on information quality, family involvement, and decision-making. The total satisfaction (TS24) score falls within the range of 0 to 100%.

Statistical analyses

Statistical analyses were conducted using GraphPad Prism 8.0. Categorical data were assessed with Fisher's exact test or the chi-square test, while the distribution of continuous data was checked with the Shapiro-Wilk test. Data normally distributed were presented as mean ± SD, and non-normally distributed data as median (IQR). Group comparisons for continuous data utilized the independent t-test or Mann-Whitney test, and within-group comparisons at different time points employed the Wilcoxon matched-pairs signed-rank test.

RESULTS

Baseline characteristics of control and intervention groups

Table 3 summarized baseline data for two groups, the control group (n = 49) and the intervention group (n = 49), within a total sample of 98 patients. Key characteristics such as age, gender distribution, PUs stage, location of ulcers, comorbid conditions (including sepsis, myocardial infarction, congestive heart failure, cerebral vascular disease, chronic pulmonary disease, and diabetes), and the Braden Scale score at ICU admission were examined. No statistically significant differences were observed between the two groups at baseline for any of the characteristics (P < 0.05), indicating a balanced distribution of these factors in the study.

Table 3 Baseline characteristics of control and intervention groups.

	Total (n = 98)	Control group (n = 49)	Intervention group (n = 49)	P value
Age (yr)		54 (35.5-68.5)	52 (36.5-69.5)	0.881
Gender
Male	61	29	32
Female	37	20	17	0.677
Stage
Stage I	38	20	18
Stage II	39	21	18
Stage III	12	6	6
Stage IV	2	1	1
Unstageable	7	1	6	0.419
Location
Coccyx	36	20	16
Buttocks	14	8	6
Trochanter	10	5	5
Scapila	8	4	4
Malleolus	8	4	4
Head	5	3	2
Heel	7	3	4
Elbow	10	2	8	0.700
Comorbid conditions
Sepsis	45	24	21	0.685
Myocardial infarction	1	1	0	1.000
Congestive heart failure	29	16	13	0.659
Cerebral vascular disease	2	0	2	0.495
Chronic pulmonary disease	14	8	6	0.774
Diabetes with complication	4	2	2	1.000
Diabetes without complications	20	9	11	0.803
Total braden at ICU admit		14 (10-20)	13 (10.5-18.5)	0.565

ICU: Intensive care unit.

Comparison of PUSH score before and after intervention (four period assessments) in two groups

As depicted in Figure 1, at day 0, there were no significant differences in PUSH total scores and its three parameters (surface area, the amount of exudate, and tissue type) between the two groups (all P > 0.05). However, concerning surface area scores, the intervention group exhibited notable reductions compared to the control group on day 6 (P = 0.007), day 9 (P = 0.001), and day 12 (P < 0.001). Furthermore, significant differences between the two groups were observed only in exudate (P = 0.049) and tissue type (P = 0.040) scores on day 12. Additionally, the intervention group displayed a significant reduction in total scores compared to the control group on day 6 (P = 0.007), day 9 (P = 0.002), and day 12 (P < 0.001).

Figure 1 Comparison of pressure ulcer scale for healing score before and after intervention in two groups.

Table 4 illustrated that, in comparison to day 0, the control group's reduction in surface area showed a significant difference on day 3, with the median score decreasing from 7 (IQR: 4-9) to 7 (IQR: 4-8.5) on day 3 (P < 0.05). However, no significant differences were observed in surface area scores on day 3, 6, 9, and 12 (all P > 0.05). Exudate (drainage) remained consistent with a median score of 1 (IQR: 0-2) throughout the study, with significant changes from day 6 to day 12 when compared to day 0 (all P < 0.05). The median score of tissue type decreased from 2 (IQR: 1-2) on day 0 to 1 (IQR: 1-2) on day 12, demonstrating statistical significance on day 9 and day 12 compared to day 0. Total PUSH scores significantly decreased on days 3, 6, 9, and 12 compared to day 0 (all P < 0.05). In the intervention group, the surface area displayed a significant reduction on day 3 (median: 5, IQR: 3-7.5) compared to day 0. This reduction continued on subsequent days, reaching a median score of 4 (IQR: 2-6) on day 12. Wilcoxon matched-pairs signed rank tests conducted at each time point revealed statistical significance (all P < 0.05). Exudate (drainage) exhibited a significant decrease from day 0 to day 3, with further reductions observed until day 12 (all P < 0.05). Exudate scores also exhibited significant reductions between day 6 and day 9 (P < 0.05). Tissue type demonstrated improvements, with a decrease in median score from day 3 to day 9 compared to day 0 (all P < 0.05). On day 12, the intervention group showed higher tissue type scores compared to day 0 (all P < 0.05). The intervention group significantly reduced total PUSH scores on day 3 compared to day 0, and these reductions persisted from day 6 onwards (all P < 0.05).

Table 4 Comparison of pressure ulcer scale for healing score before and after intervention in two groups.

Time points	Control group (n = 49)				Intervention group (n = 49)
	Surface area	Exudate (drainage)	Tissue type	Total scores	Surface area	Exudate (drainage)	Tissue type	Total scores
Day 0	7 (4-9)	1 (0-2)	2 (1-2)	9 (5-13)	6 (3-8)	1 (0-2)	1 (1-2)	10 (5-11.5)
Day 3	7 (4-8.5)a	1 (0-2)	1 (1-2)	9 (5-12.5)a	5 (3-7.5)a	1 (0-1)a	1 (1-2)a	8 (4-10.5)a
Day 6	7 (4-8)a	1 (0-2)a	1 (1-2)	9 (5-12)a,b	5 (2.5-7)a,b	1 (0-1)a,b	1 (1-2)a	8 (4-9.5)a,b
Day 9	7 (4-8)a	1 (0-2)a	1 (1-2)a	9 (5-12)a,b	4 (2-6)a,b,c	1 (0-1)a,b	1 (1-2)a	6 (3-9)a,b,c
Day 12	7 (4-8)a	1 (0-2)a	1 (1-2)a	9 (5-12)a,b,c	4 (2-6)a,b,c,d	0 (0-1)a,b,c	1 (1-2)a,b,c,d	6 (3-8)a,b,c,d

^aSignificant differences compared to day 0.

^bDenote significant differences compared to day 3.

^cSignificant differences compared to day 6.

^dSignify significant differences compared to day 9.

Comparison of family satisfaction between the two groups

Figure 2 revealed a comparison of satisfaction levels measured by FS ICU-24 questionnaires between the control and intervention groups. In terms of satisfaction with care, the intervention group exhibited a significantly higher median score (65.0) compared to the control group (56.7, P = 0.034). Similarly, satisfaction with decision was notably higher in the intervention group (59.3) than in the control group (48.0, P = 0.022). Overall satisfaction followed the same trend, with the intervention group recording a significantly higher average score (62.1) in contrast to the control group (54.3, P = 0.001).

Figure 2 Comparison of family satisfaction measured by family satisfaction ICU 24 questionnaires between the two groups. FS ICU-24: Family satisfaction ICU 24.

DISCUSSION

In this study, I incorporated the use of silver nanoparticle dressings for the treatment of PUs in critically ill trauma patients. Silver nanoparticle dressings promote wound healing by releasing silver ions, which possess both antimicrobial and anti-inflammatory properties, potentially enhancing blood flow around ulcers[16]. These dressings not only reduce the production of inflammatory cytokines but also regulate interferon activity and exhibit anti-inflammatory effects related to alpha necrotic factors, contributing to improved healing outcomes[17,18]. Therefore, this research focused on evaluating the impact of bundled care in conjunction with silver nanoparticle dressings on PU management and its effects on family satisfaction.

The balanced baseline characteristics of the control and intervention groups were pivotal in ensuring that any observed differences in outcomes could be attributed to the intervention rather than confounding factors. Critically ill patients with pressure injuries are particularly challenging to manage due to various factors that impede wound healing, such as the increased use of medical devices and medications, hemodynamic instability, and immobility[19]. Many valid and reliable tools and techniques are available for wound measurement, and the recently developed PUSH was created to monitor healing over time[20]. As reported, 20% of wounds were healed within the target of 10 d[21]. Therefore, in this study, the assessments of healing process were conducted before the application of dressings (day 0), as well as on day 3, day 6, day 9, and day 12. The study revealed that the intervention group demonstrated substantial reductions in surface area scores compared to the control group on days 6, 9, and 12. Significant differences between the two groups were also noted in exudate and tissue type scores on day 12. Additionally, the intervention group consistently exhibited lower total scores on days 6, 9, and 12 compared to the control group. These findings suggest that the combination of bundled care and silver nanoparticle dressings has a synergistic effect on PU healing.

Patient satisfaction is a well-recognized measure of healthcare quality, while family satisfaction often serves as a crucial surrogate for patient satisfaction within the ICU settings[22]. However, this should not lead clinicians to assume that there is no need to prioritize and improve family satisfaction in ICU care, as multiple international studies have demonstrated its value in identifying areas for enhancement[23,24]. In this study, I employed the FS ICU-24 questionnaire, a validated tool tailored to gauge the satisfaction of relatives concerning the care provided and their involvement in decision-making for their close family members in the ICU[25]. This questionnaire allowed us to comprehensively explore the perspectives of family members engaged in the care of ICU patients. The outcomes revealed that the intervention group attained significantly higher satisfaction scores in both care and decision satisfaction compared to the control group. This implies that the implementation of bundled care, characterized by a multidisciplinary approach and active family involvement, exerts a positive influence not only on clinical outcomes but also on the satisfaction of the patient's family. This is a pivotal aspect of patient care, as family satisfaction can markedly affect the overall care experience and its quality.

The study included a relatively small sample size of 98 patients, which may limit the generalizability of the findings to larger and more diverse patient populations. Future studies with larger cohorts could provide more robust evidence. The study's follow-up period was limited to 12 d. Assessing the sustainability of the observed improvements over an extended period would provide a more comprehensive understanding of the intervention's effectiveness.

CONCLUSION

The combination of bundled care and silver nanoparticle dressings appears to be a promising approach for the management of PUs in critically ill trauma patients. This approach not only promotes wound healing but also enhances family satisfaction, emphasizing the importance of a holistic patient-centered care model. Further research and clinical implementation may lead to better outcomes for this patient population.