Defense Date


Document Type


Degree Name

Doctor of Philosophy



First Advisor

Dr. Jo Robins, PhD, RN

Second Advisor

Dr. Leroy Thacker, PhD

Third Advisor

Dr. Alison Montpetit, PhD RN

Fourth Advisor

Dr. Joyce Black, PhD, RN, CPSN, CWCN, FAAN (Nebraska)

Fifth Advisor

Dr. Jill Cox, PhD, MSN, RN, CWOCN (Rutgers)



Cardiac surgery patients have some of the highest reported incidence and prevalence of pressure injuries (PI). A growing subset of cardiac surgery include patients with end-stage heart failure who undergo ventricular assist device (VAD) or total artificial heart (TAH) surgery. The risk of PI and their natural history of development in this population are unknown and the specific risk factors for PI development remain unexplored.


To perform a systematic review of the literature to identify the incidence and risk factors of PI development in patients undergoing VAD-TAH surgery and thereby inform study design and variables in an eight-year retrospective study of all patients undergoing VAD-TAH surgery at a large academic university medical center.


The preferred reporting items for systematic reviews and meta-analyses or PRISMA statement guided this systematic review. Quality of evidence was determined using the Johns Hopkins Nursing Evidence-Based Practice Rating Scale. Two reviewers independently appraised manuscripts matching the eligibility criteria for study inclusion. Four databases including PubMed, CINAHL, Web of Science, Google Scholar, and hand searches of journals based on reference lists from included studies were utilized. Initial results of this primary search revealed zero studies that met inclusion and this search methodology was confirmed by medical librarian consultation. Therefore, a follow up retrospective study was necessary to identify incidence of PI in the VAD-TAH population. However, a secondary search, dropping keywords of VAD-TAH and instead focusing on studies of on-pump cardiac surgery and mixed surgical studies where cardiac surgery patients were included, was conducted to establish variables to guide a retrospective study of all VAD-TAH surgeries between 2010-2018. The retrospective study evaluated the incidence of pressure ulcers by case, patient and incidence density for each of the respective 1000 patient days during the study period. Univariate statistics are reported by four different VAD-TAH devices. Variables significant in bivariate analysis were entered in a stepwise logistic regression model.


In the systematic review, 312 articles were identified from the databases with eight additional articles from hand searches. Following abstract review, 208 were excluded for not meeting inclusion criteria or study quality metrics. 77 articles were read in full, with 61 excluded, leaving 16 articles for inclusion. 31 risk factors were identified for PI development in on-pump cardiac surgery patients with 11 risk factors which were identified as significant in multivariate analysis for inclusion in the retrospective study.


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C. Brindle - Manuscript - Incidence and Predictor Variables of Pressure Injuries in Patient.pdf (661 kB)
This is the PRISMA systematic review manuscript that preceded the existing dissertation manuscript entitled: Incidence and Predictor Variables of Pressure Injuries in Patients Undergoing Ventricular Assist Device and Total Artificial Heart Surgeries: An Eight-Year Retrospective Review