Exploring Risk Factors for Pressure Injury Development Among Nursing Home Residents

Abstract

AbstractPressure injuries (PrIs) affect more than 2.5 million patients annually in the United States, with over 80% occurring in older adults (≥65 years) who are especially vulnerable due to age-related physiologic changes, chronic illnesses, and functional decline that often necessitates nursing home (NH) placement. Once developed, PrIs can have devastating consequences including increased pain, secondary infection, risk of amputation, decreased quality of life, and even death. With an estimated annual $26 billion in associated cost, PrIs present a significant burden to both individuals and the healthcare system. Despite widespread implementation of established repositioning prevention protocols, PrI rates continue to rise in NHs, with documented racial and ethnic disparities showing Black and Hispanic residents experiencing disproportionately higher rates and more severe injuries. However, limited research has examined risk factors associated with PrI development in NH residents, with existing studies showing inconsistent findings and gaps in our understanding of what factors contribute to PrI development in this population. This dissertation employed a multi-phase approach to examine risk factors associated with PrI development among NH residents. The research began with a comprehensive scoping review analyzing 12 studies from six countries published between 1992-2023 to establish the current state of knowledge regarding PrI risk factors in this population. Subsequently, a retrospective study was conducted using secondary analysis of comprehensive electronic health record data from the 12-month preintervention period of the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) pragmatic cluster randomized controlled trial. This study included 998 residents across nine NHs, employing multivariable logistic regression to examine both resident-level and facility-level risk factors associated with PrI development. Finally, to investigate observed racial and ethnic disparities in PrI rates, the Peters-Belson variance decomposition method was utilized to quantify and partition the explained and unexplained portions of disparities between Black or Hispanic residents (n = 330) and non-Black or Hispanic residents (n = 660). The findings suggest that intrinsic resident-level factors such as clinical severity indicators and mobility limitations, along with extrinsic facility-level factors including staffing patterns, are associated with PrI development in the NH population. Additionally, the research revealed substantial racial and ethnic disparities in PrI rates, with the majority of these disparities remaining unexplained by known risk factors. This research highlights the importance of holistic risk assessment approaches that consider both physiological and organizational factors as important targets for interventions. These findings emphasize the urgent need for more comprehensive, individualized risk assessment tools that incorporate both intrinsic physiological markers and extrinsic facility-level factors beyond traditional measures. Additionally, more objective assessment methods that can effectively identify early tissue damage across diverse populations to develop prevention strategies specifically tailored to this vulnerable older adult population.