Epidemiological Characteristics and Prevention of Pressure Injury in Older Inpatients of Zhuang and Han Ethnicity in Guangxi, China: A Cross-Sectional Study

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Pressure injury (PI), also known as pressure ulcer or pressure sore, is a local injury to the skin and/or deep soft tissue caused by pressure or combined shear force. It is characterized by damage to the whole skin layer with pain.¹ Owing to skin aging, loss of elasticity, and other factors, older adults constitute a high-risk group for PI.² The global prevalence of PI ranges from 4.8% to 32.2%.³ In the United States, the average treatment cost of PI care during hospitalization is $10 708 per person, with an estimated annual total expenditure exceeding $26.8 billion.⁴ After cancer and heart disease, PI is the third leading cause of high treatment and care costs.⁴ The prolonged hospitalization time and increased medical expenses associated with PI seriously affect the quality of life of older adults and increase the burden of social and familial care.⁵

It has been reported that PI severity is associated with racial and ethnic differences.⁶ The Guangxi Zhuang Autonomous Region of China is an ethnic minority province with the largest number of Zhuang residents. There are significant differences in skin injuries among different ethnic groups in China, which may be caused by different cultures, health concepts, lifestyles, and health levels.⁷ Most previous general population studies on PI were conducted without distinguishing ethnic groups.⁸ No comparative study of Zhuang and Han populations in Guangxi, China, has yet been undertaken. Therefore, to explore the epidemiological characteristics and influencing factors of PI in older inpatients (age ≥60 years) of Zhuang and Han ethnicities and to provide targeted multicultural nursing based on local health concepts and lifestyles, the authors of the present study investigated PI inpatients from 2 tertiary hospitals in the Guangxi Zhuang Autonomous Region. The study aimed to analyze the epidemiological characteristics, prevention status, and influencing factors of PI in older inpatients of Zhuang and Han ethnicity in Guangxi, China.

This cross-sectional study was reviewed and approved by the Ethics Committee of The People’s Hospital of Guangxi Zhuang Autonomous Region (approval number: 2020NZKY-028-01). All patients or their families gave informed consent to participate in this study and signed informed consent forms. A total of 2206 older inpatients who were recruited from 2 class III grade A general hospitals in the Guangxi Zhuang Autonomous Region between April 1, 2021, and May 27, 2021, were included.

The inclusion criteria were as follows: (1) patients hospitalized for at least 24 hours, (2) patients age 60 years or older, and (3) patients with complete clinical medical records. The exclusion criteria were as follows: (1) patients with cancer; (2) volatile clinical conditions and need for emergency rescue; (3) hemodynamic instability or other reasons, such as inability to roll over for the head-to-toe skin examination; (4) refusal to perform the head-to-toe skin examination; and (5) skin problems that could affect clinical observation and evaluation.

Calculation of sample size. The sample size was calculated using the cross-sectional sample size estimation formula N = T_α²pq/D², where N represents the sample size, α represents the significance level, p is the incidence rate of the expected PI, q is (1−p), and D is the allowable error.⁹In the present study, the α level was set at .05, with T_α equal to 1.96. The PI incidence in older adults according to the domestic multicenter survey is 4.8%, which is the expected incidence rate.⁸ The allowable error was set at 1%. Using the aforementioned formula, 1756 cases were identified. Based on the likely ineffective response rate of 10%, 1951 patients who met the eligibility criteria were included.

General information investigation. The general information questionnaire designed by the researchers of the present study was used to collect general demographic data, such as age, sex, educational background, and ethnicity. Moreover, the questionnaire included 13 items, including caregivers of patients with PI, department of admission, nutrition route, daily water intake, defecation and urination status, and PI occurrence (location, stage, and source).

Medical history and current medications. Patients’ medical histories included cerebrovascular diseases; diabetes; malignancies; autoimmune diseases; Parkinson syndromes; hematological diseases; paralysis; peripheral vascular diseases; kidney, lung, and other diseases; and major surgery under general anesthesia. Medications included hormones, immunosuppressants, antibiotics, painkillers, vasoactive drugs, anticoagulants, antineoplastic drugs, antihistamines, antipsychotics, sedatives, anti-diabetic drugs, anti-hypertensive drugs, diuretics, and other drugs.

PI risk factor assessment. The 6-item Braden Scale was used to assess risk of PI: perception ability, humidity, mobility, nutrition, shear, and friction. Out of a total score of 23 points, the risk of PI was scored as follows: greater than 16, no risk; 15 or 16, low risk; 13 or 14, medium risk; and less than or equal to 12, high risk.¹

Prevention status assessment. The Epidemiology and Prevention of Skin Injuries in the Elderly Scale and the Skin Injury Survey Scale were developed by Guo et al¹⁰ in 2015 and optimized and revised by Wei et al in 2021² by references and guidelines.^12,13 This scale included 34 items in 4 dimensions, including daily skin care, mattress used, dressing used at the compression site, and turning frequency. The Cronbach α was 0.874, and content validity (item content validity index, I-CVI) was 0.95 to 1.00 for the current study.

PI staging criteria. According to the recommended staging of the National Pressure Injury Advisory Panel (NPIAP),¹ PI was divided into stages 1 through 4, unstageable, and deep tissue (Table 1).

Quality control. Before the formal investigation in the present study commenced, the core members of the research team (Q.X.J. and D.F.C.) conducted unified training and assessment of the investigation nurses, which involved training on the identification, staging, and Braden Scale score of PI. A training score of 90 or higher was considered the qualification for participation in the investigation.¹⁴ Nurses who passed the training and assessment were assigned in pairs. During the investigation, the nurses observed and examined patients’ skin conditions using the investigation process and method of unified training.¹⁵ They completed the study questionnaire by reviewing the patients’ medical records and consulting the patients’ doctors and family members. If there were different opinions about a patient’s damaged skin, experts from the research team discussed the case, finalized their assessment, and provided feedback. Afterward, the final data were checked by 2 experts (Q.X.J. and D.F.C.).

Statistical analysis. SPSS Statistics v25 (IBM Corp) was used for statistical analysis. Measurement data on general information were expressed as mean (standard deviation [SD]), and an independent sample t test was used for comparison of the 2 groups. Enumeration data were represented by frequency (n) and constituent ratio (%), and comparison between the two groups was performed using the c² or Fisher exact probability test. Logistic regression analysis was used to analyze the risk factors, and a two-sided t test was used to test all hypotheses. Statistical significance was defined as P < .05.

General clinical information. A total of 2206 older inpatients were included in the study. Of this total, 555 patients (25.16%) were of Zhuang nationality, with a mean (SD) age of 69.70 (6.97) years. In this group, there were 342 males (61.60%) and 213 females (38.38%), and those with a primary school education accounted for the largest proportion by education level (33.69%). The remaining 1651 patients included in the study (74.84%) were of Han nationality, with a mean age of 71.34 (7.90) years. In this group, there were 926 males (56.09%) and 725 females (43.91%), and those with a primary school education accounted for the largest proportion by education level (32.77%). Among the Zhuang older inpatients, there was a statistically significant difference in the prevalence of PI among different caregivers (P < .05). There was a statistically significant difference in PI prevalence among Han older inpatients of different ages, in different hospital departments, and cared for by different caregivers (P < .05) (Table 2).

Prevalence of PI by ethnic group. The overall PI prevalence was 2.58% (57 of 2206). The PI prevalence was slightly higher in Han patients than in Zhuang patients (2.85% and 1.80%, respectively, c² = 1.802; P = .179). In both groups, most inpatients had stage 1 or stage 2 PI. Fifty-seven patients with PI had skin injuries. The total number of skin injuries was 64 (1.12 per capita); 5 of the 57 patients (8.77%) had more than 2 skin injuries. The most common sites of PI in the Zhuang patients were the sacrococcygeal region, foot and ankle, and spine, while in the Han patients the most common sites of PI were the sacrococcygeal region, heel, foot and ankle, and greater trochanter, and other (Other = 6) (Table 3).

Braden Scale score and protection of skin injury. The mean (SD) Braden Scale score was 18.89 (3.96) and 18.94 (3.93) for Zhuang and Han patients, respectively (c² = 24.691, P = .102). In terms of protecting patients at risk of PI, Zhuang and Han patients, respectively, had the following characteristics: 74.14% and 77.46% received daily skin care, 1.81% and 1.49% used a decompression mattress, 0.68% and 0.97% were treated with decompression dressing, and 3.17% and 3.96% were regularly turned over. The number of patients by skin care characteristic deemed to be at no risk of PI by Braden Scale score (<16 points) and at risk of PI by Braden Scale score (³16 points) is shown in Table 4.

Univariate analysis of PI in the two ethnic groups. The patients were divided into occurrence and non-occurrence groups, based on the occurrence of PI. There were significant differences between the two groups in Braden Scale scores, daily water intake, feeding route (nasal or oral), defecation (continence or incontinence), urination (continence or indwelling catheter), disease history (cerebrovascular and pulmonary diseases), and antibiotics (P < .05 for all). Within the Han group, there were statistically significant differences in the Braden Scale scores, daily water intake, feeding route (nasogastric or by mouth), defecation (continence or incontinence), urination (continence, incontinence, or indwelling catheter), disease history (cerebrovascular disease, Alzheimer disease, malignant tumor, Parkinson disease, paralysis, kidney disease, pulmonary disease), and drug utilization (antibiotics, vascular active drugs, anticoagulants, sedatives, antihypertensive drugs, diuretic drugs) (P < .05 for all) (Table 5).

Multivariate analysis of PI in the two ethnic groups. Multivariate logistic regression analysis was done, with the occurrence of PI as the dependent variable (occurrence = 1, non-occurrence = 0), and statistically significant items in univariate analysis as the independent variables (Table 5). The results showed that the main influencing factor for PI in the Zhuang group was caregivers (P < .05) and that the main influencing factors for PI in the Han group were urination (continence, incontinence, indwelling catheter), Alzheimer disease, sedatives, and antihypertensive drugs (P < .05 for all) (Table 6).

In the present study, the overall prevalence of PI was 2.58% (1.80% and 2.85% in persons of Zhuang and Han nationality, respectively), which is lower than the incidence rate of PI in countries other than China (3.4%-30.1%)^16,17 and in a Chinese multicenter study (3.1%).⁷ The difference in PI prevalence may be related to the use of scientific methods to monitor and manage PI in inpatients in the institutions of the authors of the present manuscript.¹⁸ In the present study, there was no significant difference in the PI incidence rates between the 2 ethnic groups, which may be related to the small sample size of Zhuang patients. Future research should include a larger sample size to obtain a more accurate comparison.

In the present study, 80.00% of Zhuang and 78.72% of Han patients sustained PI outside the hospital, a higher rate than among patients in a Turkish study (44.3%).¹⁹ The higher rate in the present study may be the result of patients and their caregivers in the present study not paying enough attention to PI or taking reasonable nursing measures to either prevent or resolve it on their own. In addition, in both groups in the present study, a majority of PIs occurred in the sacrococcygeal region; this finding is similar to that of a study of PI in nursing homes in eastern China.² In the present study, stage 1 PI was most common among Zhuang patients (prevalence of 60%) and stage 2 PI was most common in Han patients (prevalence of 51.06%); both of these proportions were higher than the results of a PI study in Europe (stage 1, 32.35% and stage 2, 27.59%) for context of comparison with Moore et al.²⁰ This difference in proportions of stage 1 and 2 PIs between studies may be due to the lack of regular turning over of 85.4% of the patients in the present study; in addition, other studies have confirmed that most stage 1 PIs were reversible.²¹ Identifying and initiating preventive care is the focus of preventing PI, and risk assessment should be performed within 8 hours of admission to a health care facility.

In the present study, the prevalence of PI was higher in patients without risk of PI than in patients at risk of PI (10.06% and 0.24%, respectively, based on Braden Scale score; P < .01); this result may be related to insufficient nursing due to lack of adequate training on the identification of PI risk as well as inadequate assessment of PI risk factors. Therefore, future PI prevention efforts in older patients should focus on improving nurses’ ability to accurately identify PI risks and improving nursing care.²² In the present study, the utilization rate of decompression tools in Zhuang and Han patients at high risk of PI was only 28.26% and 24.68%, respectively, with only standard hospital mattresses used for the other patients at high risk of PI. There was a serious lack of nursing care, which was considered to be due to a lack of corresponding technical equipment support. The proportion of Zhuang and Han patients in the present study who were regularly turned over was 41.30% and 56.04%, respectively, which is lower than that in another Chinese study.²³ In addition, the proportion of Zhuang and Han patients who used skin dressings was 10.14% and 13.62%, respectively. In terms of the current situation of skin prevention measures for older inpatients of Zhuang and Han nationality, the main preventive measure used was controlling the frequency of showers and water temperature. Other skin care measures were less frequently implemented, which suggests that medical staff should fully consider the local situation and potentially enhance these measures.

Based on the skin injury status of older patients as well as NPIAP and European Pressure Ulcer Advisory Panel guidelines recommendations,^1,24 training programs related to PI risk assessment and prevention strategies were developed for the People’s Hospital of Guangxi Zhuang Autonomous Region. Clinical nurses, especially those in departments with patients at high risk of PI, were trained at different levels, with attention paid to local ethnic minorities. A relatively easy-to-understand health education method²⁵ was adopted to educate patients and their families on the harm of PI and measures to prevent it. The importance of prevention in reducing the occurrence of PI was emphasized. In addition, long-term chronic diseases can lead to severe economic situations for families, which in turn affects the ability to afford and use decompression devices. This economic strain limits the access to and use of necessary medical equipment for PI prevention, such as decompression mattresses and cushions.

Controversy has always existed about the influence of patient sex and age on the occurrence of PI. The present study showed that sex did not affect the occurrence of PI, which was consistent with the results of Van Tiggelen et al²⁶. Older adults are more prone to PI than younger persons because of intrinsic factors in the former group, such as skin aging, decreased barrier functions in combination with various diseases, and decreased physical activity. In the present study, age did influence the occurrence of PI in Han older patients. Although age as a factor was eliminated after the logistics regression analysis, older patients are a key population for PI prevention efforts. It is necessary to pay close attention to maintaining dry and clean skin and to take relevant protective measures in older adults. Regarding the incidence of PI in various hospital departments, the proportion of PI was higher in the intensive care and rehabilitation departments than in other departments, which is similar to the results of a systematic review in China.²⁷ Therefore, high-risk departments (eg, intensive care, geriatrics, internal medicine) should strengthen PI preventive measures and monitor the factors that place patients at high risk for PI.

In the present study, family members accounted for the majority of caregivers of patients with PI in both groups. The lack of PI prevention awareness among caregivers was a risk factor for PI in both groups, as exhibited by the lack of attention paid to PI by family members and their lack of relevant knowledge about prevention and care of such injuries. Research in China shows that 90% of patients and caregivers lack knowledge regarding PI and that older patients spend most of their time at home.²⁸ Therefore, in addition to the need for nursing staff to closely monitor patients at the time of diagnosis and during treatment by trained nurses, nursing staff must also monitor PI care provided by those who are not trained health professionals and help them gain an understanding of PI prevention techniques. Nursing staff should allow the patient’s family members to play a role in the management and supervision of PI.

Sedatives and antihypertensive drugs were high-risk factors for the occurrence of PI in Han older patients in the present study. The use of sedatives weakens patients’ protective motor sensation, thus increasing the incidence of PI.²⁹ However, it is unclear whether patients taking hypotensive drugs are at increased risk of PI due to hemodynamic factors that reduce the frequency of turning over. Therefore, there is a greater need for antihypertensive measures in older patients who use sedative and antihypertensive drugs.

Alzheimer disease was a risk factor for the development of PI in Han older patients. This observation aligns with previous research findings.^30,31 Patients with Alzheimer disease cannot perform postural adjustment, which results in long-term ischemia and hypoxia at the compression site, leading to PI occurrence. The risk factors for PI in Han older patients included micturition and urinary catheter. Skin irritation from urine and secretion increased skin moisture, and the gravitational pull of the urine drainage bag can cause PI.³¹ Therefore, nursing staff need to strengthen skin care for such patients, keep the skin dry and clean, and fix the positioning of the urine bag, especially when patients need to move or walk. The incidence of PI is high in older inpatients with low self-care ability, chronic disease, and systemic drug use. Thus, older inpatients with PI risks should be prioritized in terms of nursing care.³²

The present study is limited by the small sample size of Zhuang and Han patients from 2 tertiary general hospitals in the Guangxi Zhuang Autonomous Region of China. In-depth investigation and analysis of the epidemiological factors related to PI in the Zhuang population is needed. Future multicenter studies should be performed to explore the epidemiological characteristics of PI in the Zhuang population and the factors affecting patient adherence to the treatment regimen.

In the present study, the PI prevalence rates were similar in both ethnic groups. The prevention of PI in older patients of Zhuang and Han nationalities remains challenging. Staff in hospital departments in which the risk of PI is high must be vigilant in their prevention efforts. To effectively prevent the occurrence of PI, various types of health education tailored to the local environment and patient population should be adopted to adjust and improve both PI prevention and nursing measures used to manage PI.

Authors: Wanlin Peng, MM¹; Qixia Jiang, MM²; Dongmei Li, BS³; Lina Wen, BS⁴; Lixiu Mo, BS⁵; Yanfei Zhang, BS⁵; Jing Wang, BS⁶; Yan Lan, BS⁷; Qiong Yuan, BS⁸; Shanshan Lv, BS⁴; Chaoqun Bai, BS⁹; Juan Zhou, BS¹⁰; Yuqian Lu, BS¹¹; and Defeng Chen, MD⁵

Affiliations: ¹School of Nursing, Guangxi University of Chinese Medicine, Nanning, Guangxi, 530004, China; ²Department of Burns and Plastic Surgery, General Hospital Eastern Theater Command of PLA, Nanjing, Jiangsu, 210002, China; ³Wound Stoma Incontinence Nursing Clinic, Guidong People’s Hospital of Guangxi Zhuang Autonomous Region, Wuzhou, Guangxi, 543001, China; ⁴Department of Geriatric Cardiovascular Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ⁵Department of Gastrointestinal, Hernia and Intestinal Fistula Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ⁶Department of Dermatology and Venereology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ⁷Neurological Surgery, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ⁸Department of Geriatric Neurology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ⁹Department of Endocrinology and Metabolism for the Elderly, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China; ¹⁰International Medical Services; ¹¹Area of Department of Gynaecology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016, China

Disclosure: The authors disclose no financial or other conflicts of interest.

Correspondence: Defeng Chen, No. 6 Taoyuan Road, Qingxiu District, Nanning City, Guangxi Zhuang Autonomous Region, 530016, China, The People’s Hospital of Guangxi Zhuang Autonomous Region; de_feng_chen@163.com

Ethical approval: This cross-sectional study was reviewed and approved by the Ethics Committee of General Hospital Eastern Theater Command of PLA (approval number: 2020NZKY-028-01). All patients or their families gave informed consent to this study and signed informed consent forms.

Consent for publication: Informed consent was obtained from all individual participants included in the study.

Funding: This study was funded by the Project of Shanghai Wang Zhengguo Trauma Medical Development Foundation, Project Number: WZG20200101.

Author contributions: Wanlin Peng, Qixia Jiang, and Defeng Chen contributed to literature research, data analysis, statistical analysis, and manuscript editing; Qixia Jiang and Defeng Chen were guarantors of integrity of the entire study, carried out study concepts and design, defined intellectual content, and helped with manuscript preparation and review; Dongmei Li, Lina Wen, Lixiu Mo, Yanfei Zhang, Jing Wang, Yan Lan, Qiong Yuan, Shanshan Lv, Chaoqun Bai, Juan Zhou, Yuqian Lu, and Defeng Chen contributed to clinical studies and data acquisition.

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