Prevention And Management Of Medical Device-related Pressure Injuries In Intensive Care Units:a Study On Evidence-based Practice

Background:There have been marked changes in the field of clinical therapeutics in recent years,with electronic medical equipment and artificial intelligence technology having been frequently utilized to date to treat myriad diseases.As such,an increasingly number of medical devices in the treatment process also caused pressures on the skin and mucous membrane of patients.This problem has gradually attracted the attention of medical staff.The definition of medical device-related pressure injury?MDRPI?was formally proposed by National Pressure Injury Advisory Panel in 2016.However,there are few studies on the prevention and management of MDRPI in Intensive Care Units?ICUs?currently,and there is still a lack of comprehensive and in-depth exploration,even though the problems highlighted in clinical practice have existed for a long time.Therefore,it is crucial to develop a MDRPI prevention and management plan in China,and how new evidence could be generated under the premise of insufficient evidence of effective dressings for MDRPI after the application of the MDRPI project also needs to be explored.Objective:This study aimed at exploring the level of knowledge and attitude of nursing staff towards MDRPI and the current practice status of MDRPI in the ICUs,systematically reviewing,evaluating and synthesizing relevant evidence related to MDRPI prevention and management,developing the program of MDRPI prevention and management in the ICUs,describing process of gradual introduction of this evidence into clinical situations,and evaluating its feasibility and effectiveness.It also aimed at exploring the effect of a thermo-sensitive hydrogel dressing containing mesenchymal stem cells?MSCs?derived exosomes by constructing cell model and animal model of MDRPI.Methods:This study takes the JBI Model of Evidence-based Healthcare as the theoretical framework,and was carried out in a total of five steps:clinical context and professional judgement,evidence synthesis,evidence transfer,evidence implementation and new evidence generation driven by evidence introduction.?1?Clinical context and professional judgement.A questionnaire survey using the Pieper-Zulkowski Pressure Ulcer Knowledge Test?PZ-PUKT?,Attitude towards Pressure Ulcer Prevention instrument?APuP?and the Nurses'Knowledge Scale of MDRPI were conducted to evaluate the level of PI/MDRPI knowledge and attitude of ICU nurses.Focus Group Interview of key informants was also implemented to describe and analyze the current practice status of MDRPI in ICUs.?2?Evidence synthesis.Evidence on MDRPI prevention and management was evaluated and integrated by a systematic review.?3?Evidence transfer.After evaluating the evidence and recommendation level according to the"JBI evidence pre-score system"and"JBI evidence recommendation level system",Expert Meeting Law was conduct to revise and improve the evidence-based practice program and the final version of the MDRPI Prevention and Management Program in ICU.?4?Evidence implementation.A prospective randomized parallel-controlled study was implemented to evaluate its feasibility and effectiveness.?5?New evidence generation driven by evidence introduction.Thermo-sensitive hydrogels carrying MSC exosomes was obtained with Pluronic F127 and F68.Hydrogen peroxide-induced oxidative stress models in mouse myoblasts and magnet periodic clipping-induced skin injury models were used to explore the role of this novel dressing in resisting cell injury and promoting tissue repair of MDRPI.Results:?1?Cronbach's?values of PZ-PUKT,APuP and Nurses'Knowledge Scale of MDRPI were 0.932,0.899 and 0.760,0.899 and 0.760.The validity of content was also acceptable?I-CVI=0.83-1.00,S-CVI=0.945-0.957?.The average standardized score of 306 ICU nurses in PK-PUZT?69.42%?,APuP?3.86%?and Nurses'Knowledge Scale of MDRPI?74.52%?were relatively low.The results with Focus Group Interview of 15 experts extracted four related topics:high incidence of MDRPI,inadequate attention,lack of knowledge and relatively insufficient nurses.?2?A total of 9 evidence-based clinical practice guideline?CPG?,2 evidence summaries and 8 systematic reviews were included.The overall quality of the CPGs was good,with the highest standardized score in the field of"scope and purpose"and"rigour of development",and the lowest standardized score in the field of"applicability".The quality of evidence summaries and systematic reviews were all above medium.The main elements of the evidence mainly include risk assessment;selection,application and removal of medical devices;selection and application of preventive dressings;preventive skin care;support surfaces and re-positioning;nutritional support;education and supervision.?3?Best Practice Information Sheet of MDRPI Prevention and Management including51 items in 7 aspects were developed through evaluating the level of the evidence and recommendation.The final version of MDRPI Prevention and Management Program including 30 items in 6 aspects in ICU had been revised in structure and contents with Expert Meeting Law.?4?The incidence of MDRPI in the intervention group?1.83%?was significantly lower than that in the control group?7.47%?after clinical application of the evidence-based practice program;and the standardized scores of PK-PUZT?80.25%?,APuP?83.08%?and Nurses'Knowledge Scale of MDRPI?90.15%?of nurses were significantly higher in the intervention group than those in the control group;the overall implementation rate of nurses for MDRPI prevention and management programs was 95.14%;the satisfaction of family members of both groups was at a high level during the practice period.?5?The phase-transition temperature of normal saline with 220 mg/mL F127 and 100mg/mL F68 was 36.1?,most closest to the body surface temperature,and without cytotoxicity.In addition,100?g/mL exosomes can promote the proliferation and migration of C2C12 cells and resist the oxidative stress induced by H₂O₂.The results of animal experiments show that the application of exosome hydrogel wound dressing can reduce the wound area,accelerate wound healing,and improve the expression of HGF?TGF-??PDGF and MMP9 in the wound tissue.Conclusion:?1?The knowledge and attitude level of the PI/MDRPI of ICU nurses in China need to be improved,and the practice of clinical medical staff on the MDRPI of intensive care patients has shortcomings.?2?The formulated MDRPI Prevention and Management Program is effective and feasible to a certain extent in domestic clinical situations.?3?MSC exosome thermo-sensitive hydrogel dressing plays an important role in resisting ischemia-reperfusion injury and promoting regeneration repair.It can be applied as a new regenerative approach of wound care.