Incidence of Hospital-Acquired Pressure Injury among Adult Inpatients at Kakamega County General Hospital, Kenya

A hospital-acquired pressure injury is a largely preventable adverse health event, which has remained high volume and high cost globally hence a significant concern in healthcare. This study used a prospective cohort model between April and July 2021 to determine the incidence of these injuries among adults at the Kakamega County General Hospital in Kenya, thus informing the need for scaled-up intervention strategies to eliminate these preventable harms on patients receiving care in line with international patients’ safety goal. Eighty participants above 18 years of age, systematically drawn from the male and female medical, surgical, and orthopaedic hospitalisation units, were followed up through their hospital stay for the development of pressure injury. Sociodemographic characteristics, units of hospitalisation, diagnosis and clinical variables were studied and outcomes were recorded, coded,


INTRODUCTION
Pressure injury, popularly known as pressure ulcers or bed soreness, is localised skin and/or underlying soft tissue damage from intense unrelieved pressure in combination with shear and/other conditions (National Pressure Ulcer Advisory Panel, 2009). The injured part, usually in areas of bone prominence, may remain with intact skin or break into painful ulceration that is prone to infections (Edsberg et al., 2016). Intense and prolonged pressure is considered the single major player in the formation of a pressure injury, besides factors that influence tissue tolerance (NPUAP, 2011).
The development of pressure injury is relatively common including in hospitals and compounding care (Catherine et al., 2009). Data extracted from the 2019 Global Burden of Disease Study (GBD) revealed a burden of 11.3 persons per 100,000 populations globally and 4 cases per 100,000 populations in Eastern Sub-Saharan Africa (Xianghong et al., 2021). A review of epidemiological studies in Europe, Canada and the USA summarised the reported prevalence of pressure ulcers in European hospitals as ranging from 8.3% to 23% (Catherine et al., 2009;Ahmad et al., 2018). The incidence similarly has been on the increase, recording an 80% increase between 1995 and 2008, with 2.5 million patients developing a pressure injury annually in the US alone (Catherine et al., 2009;Gyeong et al., 2019;Ahmad et al., 2018;VanGilder et al., 2017).
Cost-wise, pressure injury is imposing a huge financial burden on the healthcare system, costing about 11 billion US dollars in the United States alone per year, with the cost of care on individual patients ranging between $20,900 to $151,700 per pressure injury as reported by the Department of Health and Human Services, Centres for Medicare & Medicaid Services in 2008 (Brem et al., 2010). Considering this level of financial demand, pressure injuries not only impact the health and quality of life for the patient and their family but also cause considerable financial strain on the patient, their family, and the health care system hence a big concern (Squitieri et al., 2018).
There is limited research and scanty publications on this important topic in Kenya, particularly in Kakamega County. It is therefore impossible to determine the burden with an acceptable level of certainty from existing literature. Nangole, in 2003, conducting a study at Kenyatta National Hospital (KHN) and the National Spinal Cord Injury Hospital (NSCIH), established an overall prevalence of 5.5% in Kenya, with up to 68% in patients admitted at the NSCIH (Nangole et al., 2009). This is likely to be higher today if the trends established in Canada, the UK, the USA, and other places are to go by (VanGilder et al., 2017;Gyeong et al., 2019).
This study aimed to objectively evaluate the local epidemiology of hospital-acquired pressure injury, focusing on the incidence among adult inpatients at Kakamega County General Hospital (KCGH). This is a requirement for the implementation of the international guidelines for the prevention and treatment of pressure injury/ulcers (EPUAP, NPIAP, & PPPIA, 2019) towards safe hospitalisation (JCI, 2019). This will inform the need for enhanced pressure injury prevention and strengthen management strategies for safer hospitalisation, improving equity, quality, and affordability of healthcare, propelling UHC, which is a flagship project of the 'Big Four' agenda of the Republic of Kenya 2017-2022 (Wangia & Kandie, 2019;Edwine et al., 2019;PSC, 2018).

Study Objective
The objective of this study was to determine the incidence of hospital-acquired pressure injuries among hospitalised adult patients at the Kakamega County General Hospital (KCGH). Specifically; 1. To determine the incidence of hospitalacquired pressure injury among hospitalised adult patients at the KCGH.
2. To identify the body site(s) commonly affected by pressure injury among hospitalised adult patients at the KCGH.

Study Area
This was a single-site study conducted from April 20 2021 to July 20 2021, at the Kakamega County General Hospital in Kakamega County (KCGH) in the western region of Kenya. The KCGH is a public referral health facility serving a large and diverse population and has a wide range of medical and clinical services.

Study Design
A prospective cohort study design was employed. The cohorts were recruited at the time of admission and followed up during the hospitalisation period for the development of stage 2 or above pressure injury.

Target Population
Adults admitted in the orthopaedic wards, medical wards, and surgical wards, with the expected hospital stay lasting at least five days, were targeted.

Exclusion Criteria
Patients with pressure injuries present on admission.

Sampling
The minimum sample size was determined using the Cochran formula (Nam, 1992) plus an attrition rate of 10%. The sample was then corrected for a definite population and distributed proportionally across the three selected hospitalisation units. Every even number of admission in the units meeting the inclusion criteria was selected until the desired population size was achieved.

Data Collection and Analysis
A questionnaire coupled with a comprehensive observation and examination checklist was used to gather the required information from the uniquely identified consenting study participants. Demographic data, clinical information, and complete skin examination findings were captured at admission. Re-examination and skin check for pressure injury development were done every 48 hours during hospitalisation until a stage 2 or above pressure injury developed or the patient was discharged.
The collected data were coded and analysed on a statistical package for social sciences (SPSS) version 26.0. This was then presented using tables and charts.
From the chart below, it is clear that more men had a trauma diagnosis; however, more women had a chronic illness and were also overweight.

Clinical Characteristics and Outcome
With respect to the clinical condition of the participants, HAPI cases were fairly distributed, with 16.2% of cases (n = 2), each occurring among those principally diagnosed with gastrointestinal, neuromuscular, and urogenital pathologies. 41.7% (n = 5) of cases, however occurred among the trauma diagnosis category. 58.3% (n = 7) of cases had no chronic illness, while 25% (n = 3) had diabetes mellitus (DM)/Hypertension (HTN) coinfection. Further, 8.3% (1) had DM/renal failure co-infection and malignancy. 83.3% (n = 10) had a medical device on them, including 7 with Foley catheter, 1 having both catheter and nasal-gastric (NG) tube, and another 2 having NG tube.

Incidence of Hospital-Acquired Pressure Injury
15% of all the participants developed Pressure Injuries, n = 12. 6 cases occurred in the surgical ward, 5 in the medical ward, and 1 in the orthopaedic ward. Though the key informants generally agreed that pressure injury is more common in the surgical and medical wards, their estimates were much lower, with the highest at 6%. "Those injuries rarely occur in this hospital. Maybe in the surgical ward where about six in a hundred cases may occur on bad days..." reported one. 58.3% of the cases were males (n = 7). 66.7% were aged above 50 years (n = 8). 58.3% of cases had primary education (n = 7), with 75.0% being in informal employment (n = 9). Most cases had normal weight (n = 9; 75.0%), with trauma being the most prevalent principal diagnosis among cases (n = 5; 41.7%) and 41.7% having a chronic illness (n = 5). Diabetes/hypertension co-infection was the common chronic illness in cases (n = 3; 25.0%), 83.3% had a medical device (n = 10), and a similar proportion was from the high-risk cohort. Medical and surgical wards had an incidence rate above the overall 15%, at 19.3% and 15.8%, respectively.
Most of KIs believed bed-ridden patients were the ones at highest risk of pressure injury, especially when they are aged and stay long in the hospital. "We do not have bed-ridden patients here. Also, we discharge within a week or so, therefore getting a bed sore in this ward is very difficult," said W.

Figure 2: Incidence of HAPI in hospitalisation units
The incident rate was also higher in males (17.5%) than in females (12.5%). Among participants aged above 50 years, the incidence rate was 21.1%, compared to 9.5% in those aged 50 years and below. Participants with a medical device had an incidence of 29.4%, which is very high compared to those without a medical device, whose incidence was 4.3%. The incidence rate in the high-risk cohort (according to Braden's risk score) was 41.7% compared to 3.6% for the low-risk category. Since diagnosis is usually made clinically, some cases are likely to go unnoticed. "When you don't see a wound or a blister, you can't report that…" said Z.

Body Site Affected by HAPI
The 12 cases had a total of 14 pressure injuries occurring at seven locations; sacrum, ischium, greater trochanter, coccyx, heel, malleolus, and scapula regions of the body. Three cases were reported by day three of admission, one occurring on the sacrum, ischial tuberosity, and coccyx each. The fourth day had the highest number of cases, 28.6% (n = 4), spread across the malleolus and the heel, each reporting one injury and two in the sacrum. One PI in the sacrum was reported on the fifth day. The sixth day registered three additional injuries occurring on the sacrum, ischial tuberosity, and greater trochanter, respectively. The seventh, eighth and thirteenth days registered one injury each, occurring on the heel, scapula, and coccyx, respectively.
35.7% (n = 5) of the injuries occurred on the sacrum, four in male patients, with only one occurring in the female. Ischial tuberosity, coccyx and heel had 14.3% (n = 2) of pressure injury each. All the ischial injuries occurred in females. The greater trochanter, the malleolus and the scapula recorded 7.1% (n = 1) of the injuries each. Whereas the highest number of injuries, 28.6% (n = 4) were recorded on day 4 postadmission, days 3 and 6 also registered high numbers of 21.4% (n = 3) each. The rest of the days (5 th , 7 th , 8 th , and 13 th ) reported a single incidence each. The earliest PI was developed by day 3 with the latest recorded by day 13 (mean 5.58; SD 2.81).

Incidence
The incidence of hospital-acquired pressure injury in this study, 15%, shows that more than one of every ten adult patients admitted at KCGH ends up with HAPI, avoidable harm while receiving care. This number is quite elevated, almost twice as high, in comparison to pooled global incidence of 8.4% from a 2020 systematic review and meta-analysis and over ten times higher compared to findings from some developed countries like Sweden (Zhaoyu et al., 2020). Nevertheless, this incidence is quite similar to findings from most developing countries, like Nigeria, where Onigbinde and team recorded an incidence of 13.8% in a single-site study (Onigbinde et al., 2012). Such high incidence made Harvey describe HAPI as a low-income country scourge (Harvey, 2017).
The differences in population, healthcare set-up studied, and the period when the study was conducted mostly account for the variations in the incidence of HAPI (Zhaoyu et al., 2020), but, according to Harvey, the poor socioeconomic indicators in the low-income countries translate to poor health outcomes ahead of hospitalisation (Harvey, 2017). Low-income countries, Kenya included, have poor health infrastructure and inadequately qualified healthcare staff, affecting access and quality of healthcare and increasing susceptibility to pressure injury (Matozinhos et al., 2017). Most patients in the study had below tertiary education (81.2%) and a majority were in informal employment (65.0%), which is characteristic of low-income countries. The incidence was quite high among those with only up to primary education (22.5%) and those in informal employment (17.3%), compared to those with tertiary education (6.7%) and formal employment (8.3%). Level of education and income influence one's choice on matters of health, including the choice of when and where to seek health services (WHO, 2005). Low education and low-income results in limited information, poor nutrition, and little social support and are a hindrance to access to quality healthcare and correct choices on personal health even prior to hospitalisation, resulting in increased morbidity and increased risk of pressure injury (Harvey, 2017), similar to the findings of this study.
More males (17.5%) developed HAPI in this study compared to females (12.5%), contrary to findings from systemic review studies that found negligible differences in the occurrence and development of pressure injuries in males and females (Coleman et al., 2013). This result somehow reflects findings in Kenya, where about twice as many males (68%) had PI compared to females (32%) (Nangole et al., 2009). This difference can be attributed to gender stereotypes in nursing which could influence care and intervention (Macdonald & Bridge, 1991), where female patients are likely to receive better care compared to their male counterparts. Gender morbidity and mortality paradoxes may as well explain such gaps (Archana Singh-Manoux et al., 2008).
The average age of patients with pressure injury was relatively high (60.4; 11.2) with an incidence of 25% among the aged (=/>60 years). This is consistent with other findings that established an increased risk of pressure injury with increasing age, linked to reduced perfusion and pressure tolerance by the skin (Kayser, VanGilder, & Lanchenbruch, 2019;Borsting, et al., 2018). These findings closely replicate findings from a prospective study by Iranmanesh and team, which reported mean age of 58 years for patients who developed pressure injury, compared to 38 years for patients who did not (Iranmanesh, Rafiei, & Sabzevari, 2012). Old age, especially around 60 years and above is thus a significant intrinsic HAPI risk factor.
The orthopaedic hospitalisation unit, with relatively younger patients, recorded the lowest incidence (6.3%). The unit hosts mostly younger patients with an average age of 44 years, mostly with minor injuries from road traffic accidents (Langley & Brenner, 2004). These generally have healthier skin, good nutrition, and good circulation that improve skin tolerance to pressure, evading pressure injury (Gorecki et al., 2009). The medical hospitalisation unit recorded high incidence (19.2%), which is common in the population it houses, including aged patients (mean age; 50.7), with prevailing chronic conditions and co-morbidities reducing skin tolerance to pressure and promoting the occurrence of pressure injury (Dinkie et al., 2018). This confirms the age factor and suggests a relationship between HAPI and chronic illness which was however not established in this study.
A relatively higher incidence was also recorded among trauma patients (20%) compared to those with medical cases (12%). Trauma cases are likely to experience impaired neurological activity, immobility, and inactivity, all of which are factors that were noted to increase the risk of pressure injury in this study. This is similar to findings by Molon and Estrella who reported an overall incidence of 20% by the seventh day of a prospective cohort study among orthopaedic, basically trauma patients (Molon & Estrella, 2011).

Body Site Commonly Affected
The sacrum was the most affected body site at a frequency of 35.7% (n = 5) of all injuries. This is contrary to findings by Nangole and team (Nangole et al., 2009), who established the trochanteric region as the most frequented by pressure injury (43%), sacral (19.3%) and ischial (10.3%) at Kenyatta National and the Spinal Injury Hospitals. This difference may have resulted from the varying characteristics of the patient populations studied and the fact that their study focused on treatment, capturing all the cases including none hospitalacquired cases. The sacrum tissue lying on the prominent sacral bone bears increased and prolonged pressure as patients mostly lie supine, which may interfere with skin perfusion and promote cellular death and tissue damage, promoting the occurrence of pressure injury. The sacral region is prone to deeper pressure injuries and infection, and the recorded high frequency partly explains the increased morbidity, prolonged hospitalisation and even mortality in patients who develop HAPI, as also found by Nangole et al., 2009(Graves, Birrell, & Whitby, 2005. The heel, ischium and coccyx regions had a 14.3% frequency of occurrence of pressure injury. The anatomical difference in males and females seems to influence the occurrence of HAPI, especially around the pelvis, though this has not been highlighted in the reviewed literature. Factors around obstetrical dilemma giving rise to pubic arch in females, and sacral promontory that is more pronounced in males (Lumelcandela, 2021), is probably the reason for more ischial injuries in female patients and more sacral-coccygeal injuries in male patients. These regions require special attention during the examination and preventive management procedures. This will ensure that the injuries are prevented, otherwise detected early, and managed before progression to advanced stages.
All the pressure injury cases recorded in this study occurred within the first two weeks of hospitalisation, mostly from the third to sixth day. The mean period of occurrence was 5.6 days which is within the first two weeks of hospitalisation, in agreement with findings by (Cox, 2012).

CONCLUSION AND RECOMMENDATION
This single-site prospective cohort study at Kakamega County General Hospital found a relatively high hospital-acquired pressure injury incidence of 15%, compared to a global 8.4%, but much similar to findings from developing countries such as Ethiopia, Iran, Turkey, and some developed nations like Germany. This rate was higher in the medical hospitalisation unit (19.2%) and in males (17.5%). This translates to about two out of every ten patients developing at least a HAPI in the course of their hospital stay.
The sacrum was the most affected site, with a mean period of occurrence at 5.6 days posthospitalisation. This study, therefore, recommends the adoption, customisation, and implementation of international guidelines on the prevention and treatment of pressure ulcers/injuries both at the county and national levels to lower the incidence (EPUAP, NPIAP, & PPPIA, 2019). Also, streamlined efforts, including mandatory reporting of HAPI as a sentinel event, will increase focus on this neglected menace, promote awareness, and encourage proactive multidisciplinary, evidencebased prevention and treatment. The sacrum region (in all patients) and the ischium (particularly in female patients), among the many parts of bone prominence, should be checked regularly for very early signs of pressure injury occurrence and addressed appropriately to avert deterioration. Other studies should also evaluate HAPI in other local healthcare settings for variations in incidence and prevalence.