I read with great interest the recently published article by Pittman and colleagues examining factors associated with avoidable versus unavoidable hospital-acquired pressure injuries (HAPIs). I commend the authors for research on this topic, which is relevant to patients, nurses, health care administrators, quality organizations, and the Centers for Medicare and Medicaid Services.

The etiology of pressure injury is multifactorial; therefore, risk detection in the critical care population is complex. Research in the past decade has demonstrated the inadequacies of using the total Braden score to assess risk of pressure injury in critical care, although scores on some Braden subscales have been found to be significant predictors.2-5  Moreover, clear definitions of both acute skin failure and unavoidable HAPI are needed to enhance our understanding of the interaction of intrinsic factors affecting oxygenation and perfusion to the skin often experienced by critically ill patients.

I have several concerns...

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