Multi-State Modeling of Pressure Injury Staging Transition Trajectories to Inform Next-Generation Clinical Decision Support

Objective: This study aimed to evaluate the location-specific and time-sensitive trajectories of pressure injuries (PrIs) stages using real-world electronic health record (EHR) datasets. Approach: Using a dataset of 29,475 patients with records of PrIs documented from 2015 to 2023, we developed four PrI patient sub-cohorts with common PrI locations, including coccyx, buttocks, sacrum and heel. We estimated transition intensities between three PrI states: stage 1, stage 2, and a severe stage in each group. Stages and transition paths were derived from domain knowledge provided by clinical experts and The National PrI Advisory Panel (NPIAP) guidelines. Results: The trajectory analysis suggested that stage 2 serves as a “gateway state” in all four locations, meaning that once a PrI reaches stage 2, the likelihood of transiting to severe stages increases significantly. The commonly used Braden Scale and its sub-components are more likely to be associated with transitions from stage 2 to severe stages, suggesting that manual risk assessment tools are suboptimal for predicting early-stage PrI transitions. Further, we observed race-dependent variations across injury location groups. Innovation: To our knowledge, this is the first study to introduce multi-state trajectory analysis in PrI research. Our model can investigate PrI status in a dynamic manner, which fills an important gap in the field. Conclusion: Our findings underscore the lack of time-sensitive information in existing PrI risk assessment tools, revealing a critical gap in their ability to capture the dynamic nature of PrI progression. Clinical decision support using time sensitive data is needed for delivering personalized, timely, and effective PrI prevention.