The uptake of the international pressure ulcer/injury prevention and treatment guidelines in the scientific literature: A systematic analysis of two major citation databases

BackgroundThe European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance developed international Clinical Practice Guidelines of the prevention and treatment of pressure ulcers/injuries in 2009, 2014, and 2019. Despite substantial dissemination efforts, evidence about guideline dissemination and uptake in the international literature is lacking.AimThe aim of this review was to capture to the greatest detail possible the number of the citations of the three published Clinical Practice Guidelines.MethodsThe citation databases Web of Science and Scopus were searched for citations of the 2009, 2014 and 2019 Clinical Practice Guidelines including all derivative products including short versions and translations. Two separate search strategies were iteratively developed to ensure highest sensitivity.ResultsThe Cited Reference Search in Web of Science identified hundreds of different referencing formats with more than 2000 citing articles. The Scopus search revealed 250 different reference formats and more than 2000 citation counts. After publication there was a gradual increase of citations that peaks approximately after four years.ConclusionThe three Clinical Practice Guidelines including all derivate versions had a substantial uptake in the scientific literature. This supports the assumption that the guideline dissemination strategies were and are successful.     

Prevention and treatment of pressure injuries: A meta-synthesis of Cochrane Reviews

BackgroundThere are many high-quality systematic reviews to inform practice around pressure injury (PI) prevention and treatment. However, they are often unable to provide recommendations for practice and research due to low quality trials.ObjectivesTo evaluate current systematic review evidence on the prevention and treatment of PI.MethodsThis meta-synthesis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only Cochrane Reviews were included. Evidence from reviews was independently screened and assessed for risk of bias and certainty using Grading of Recommendations, Assessment, Development and Evaluations by two authors, with a third resolving discrepancies. Methodological quality of included reviews was assessed using the second version of A Measurement Tool to Assess Systematic Reviews, and a narrative synthesis undertaken.ResultsTwenty-five Cochrane Reviews were included; eight for PI prevention and 19 for PI treatment. Prevention reviews included 102 studies (27,933 participants). Treatment reviews included 154 studies (over 16,936 participants). Three prevention reviews and nine treatment reviews reported risk of bias, judging the included trials as having low or very low certainty evidence. Two reviews reported moderate certainty evidence. Methodological quality of the systematic reviews was rated as high for eight reviews (7/19 for treatment and 1/6 for prevention). Recommendations for prevention included repositioning, nutrition and support surfaces. Recommendations for treatment focused on nutrition and repositioning.ConclusionsThis meta-synthesis confirms the low-certainty of PI prevention and treatment trials, resulting in few recommendations to inform clinical practice. Generation of high-quality evidence on PI prevention and treatment is imperative.     

Prevalence and incidence of pressure ulcers/injuries in emergency services: A systematic review protocol

AimTo develop a systematic review protocol on the prevalence and/or the incidence of pressure ulcers/injuries in adult patients in emergency services.Materials and methodsThis protocol was developed according to the Preferred Reporting Items Form Systematic Review and Meta-Analysis Protocols (PRISMA-P) and the Joanna Briggs Institute (JBI) methodology for systematic reviews of prevalence and incidence studies. The inclusion criteria will be based on the CoCoPop mnemonic. The main variables of interest will be the “prevalence” and/or the “incidence” of “pressure ulcers/injuries” (Condition) reported in studies developed in emergency services (Context), with participants aged 18 or more (Population). This Systematic Review Protocol was registered in PROSPERO (CDR42021252906).ResultsIf meta-analysis is not possible, the syntheses of quantitative data will be presented in a narrative form to address the scope and objectives of this systematic review. Tables, graphs and/or figures will be designed to present the results of the prevalence and the incidence of pressure ulcers/injuries, their body locations and the respective categories/stages. The Systematic Review is currently ongoing.ConclusionsPrevalence and incidence systematic reviews are an emerging methodology in the field of evidence synthesis. We believe that the systematic review on prevalence and incidence of pressure ulcers/injuries in emergency services can provide useful information for healthcare professionals and policy makers about the dimension of this problem in a specific context. The standardized approach outlined in this systematic review protocol offers a rigorous and transparent method to conduct the review.     

An extracellular matrix graft (Oasis® wound matrix) for treating full-thickness pressure ulcers: A randomized clinical trial

Aim

The purpose of the study was to evaluate clinical safety and effectiveness of Oasis^® Wound Matrix as a treatment for full-thickness pressure ulcers and compare it to Standard Care.

The effect of pH-compatible cleansing cloths on skin pH and the development of pressure ulcers

AimSkin care plays an important role in the prevention of the development of pressure ulcers. The aim of this study was to determine the effect of skincare with a body pH-compatible cleansing cloth on the development time of pressure ulcers and on skin pH.MethodsThis experimental research was conducted with 156 patients hospitalized in intensive care clinics of a state hospital between September 2019 and 2020. The sample was calculated with a power of 80% and a significance level of 0.05 (α error) and as a result, 78 elderly patients formed the intervention group and another 78 elderly patients made up the control group. Data were collected using the Elderly Information Form, Braden Risk Assessment Scale, Pressure Ulcer Staging Tool and Skin pH Measurement Form. The pre- and post-care skin pH of both groups was measured with a skin pH meter. P < 0.05 was considered statistically significant.ResultsThe average development time for pressure ulcers was 14.9 days in the control group, 18.9 days in the intervention group and the difference was not statistically significant (p > 0.05). Skin pH decreased in the intervention group after the skin care routine was applied, whereas it increased in the control group.ConclusionIt can be said that care of one's skin with a body pH-compatible cleansing cloth has a positive effect on the development time of pressure ulcers and also positively changes the skin pH to acidic.     

A systematic review of prevalence and incidence of pressure ulcers/injuries in hospital emergency services

AimTo develop a systematic review on the prevalence and the incidence of pressure ulcers/injuries in adult patients in hospital emergency services.Materials and methodsSystematic review of prevalence and incidence studies developed according to the Preferred Reporting Items Form Systematic Review and Meta-Analysis Protocols and the Joanna Briggs Institute methodology. The inclusion criteria were based on the CoCoPop mnemonic. The main variables of interest were the “prevalence” and/or the “incidence” of “pressure ulcers/injuries” (Condition) reported in studies developed in hospital emergency services (Context) with adult participants (Population). The Systematic Review Protocol was registered in PROSPERO (CDR42021252906).ResultsThe pressure ulcer/injury (point) prevalence ranged from 5.2% (at admission) to 12.3% (at discharge) and the pressure ulcer/injury incidence ranged from 4.5% to 78.4%. Most of the pressure ulcers/injuries documented were category/stage I. The most problematic anatomical locations were the sacrococcygeal region and the heels. The preventive measures should be implemented as soon as possible and are important in patients older than 75 years, with multiple comorbidities, high C-Reative Protein levels, cervical spine immobilization, presented to hospital emergency service by ambulance or with hypotension at the time of admission.ConclusionsThe prevalence and incidence of pressure ulcers/injuries in hospital emergency services remains an understudied topic which could limit the generalization of our data. This systematic review highlighted that the management of pressure ulcers/injuries is a real and current challenge in hospital emergency services. It is important to identify the patients at (higher) risk to establish an (earlier) preventive care plan according to patients and emergency services’ characteristics.     

Prevalence of pressure ulcers in africa: A systematic review and meta-analysis

BackgroundA recent global review of pressure ulcers contained no studies from Africa.ObjectiveTo identify the prevalence and incidence of pressure ulcers in Africa.Data sourcesBibliographic databases, African specific databases, grey literature.Study eligibility criteriaStudies with prevalence or incidence data of pressure ulcers from Africa since the year 2000.ParticipantsAny age, including children, in any setting, specifically including hospital patients from any clinical area but not restricted to hospital settings.Study appraisal and synthesis methodsHoy score for bias, Joanna Briggs Institute Critical Appraisal Instrument.MethodWe followed the PRISMA guideline for systematic reviews. We searched Embase, Medline, Scopus, CINHAL, Google Scholar, specialist African databases and grey literature for studies reporting incidence or prevalence data.ResultsNineteen studies met the inclusion criteria and were included in the study. Point prevalence rates varied from 3.4% to 18.6% for medical/surgical and other general hospital units with a pooled prevalence of 11%, for grades II-IV 5%. For spinal injury units the pooled prevalence was 44%.Limitationsrestricted to English, French and Arabic.ConclusionPrevalence of pressure ulcers in Africa reported here is similar to figures from a recent review of prevalence in Europe and two recent global reviews of hospitalised patients. Prevalence of pressure ulcers in spinal cord injury patients is similar to figures from a review of developing countries. The reporting of prevalence is lacking in detail in some studies. Studies using an observational design employing physical examination of patients showed higher prevalence than those relying on other methods such as medical notes or databases.Implications of key findingsFurther prevalence and incidence studies are needed in Africa. Reporting of such studies should ensure items in the “Checklist for Prevalence Studies” from Joanna Briggs Institute (or similar well regarded resources) are addressed and the PICOS model and PRISMA guidelines are employed.Systematic review registration numberProspero registration number CRD42020180093     

Prevention of pressure injuries in critically ill children: A preliminary evaluation

AimsTo evaluate a prevention strategy implemented to reduce incidence and severity of positioning related pressure injuries affecting pediatric patients in a pediatric critical care unit. Secondary objective was to evaluate compliance with preventive recommendations.BackgroundThe skin in infants or children has important physiological and anatomical differences compared with adults. Further, factors such as the immaturity of the skin and limited activity and mobility in pediatric critical care unit, along with the pressure exerted by medical devices, increases the risk of pressure ulcers in infants and children. The most effective preventive measures specific to this intensive care population need to be evaluated.Material and methodsQuasi-experimental before-after study with consecutive sampling. The effectiveness of the care bundle implementation was evaluated based on the latest evidence (intervention group) versus the application of non-standardized care (control group). Pediatric patients up to 14 years old at risk of suffering from pressure injuries and who were admitted more than 48 h in a pediatric intensive care unit (level III) participated. For the collection of data, two computer programs and the hospital clinical records of each participant were consulted. The data collection period was 6 months per group (pre and post intervention).ResultsA sample of 110 patients was obtained (50 control group and 60 intervention group). The cumulative incidence in pediatric patients exposed to the risk of pressure injuries was reduced from 16% to 13.3%; and in the subgroup of patients with prolonged stay (≥28 days), the incidence was reduced from 55.55% to 20%. In the intervention group, category III and IV pressure ulcers were completely reduced. In addition, the total number of pressure injuries decreased by 21.43%. The care bandle recommendations with the highest level of adhesion recorded were: skin inspection, application of hyperoxygenated fatty acids and use of a special support surface. The main risk factor found during the study was the prone position (p < 0.05).ConclusionsThe application of a care bundle for prevention can be an effective solution to reduce the number and severity of LPPs in an intensive care unit. The most vulnerable subgroup of patients may benefit from the application of these resources.     

Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran

Background and objective

Pressure ulcer (PU) is one of the important and frequent complications of hospitalization, associated with high treatment costs. The present study was conducted to determine the incidence of PU and its direct treatment costs for patients in intensive care unit (ICU) in Iran.

Assessing the impact of a patient education programme on pressure ulcer prevention in patients with spinal cord injuries

ObjectivesThere is currently a low level of evidence for the impact of patient education on the management of patients with chronic neurological disease at risk of developing pressure ulcers. The objective of this study was to assess the impact of a patient education programme on pressure ulcer prevention in patients with chronic spinal cord injuries.Materials and methodsThis study included adult patients with any spinal cord injury, regardless of the cause. Participants attended 2 group workshops focusing on pressure ulcer prevention.Various clinical data were gathered during an initial individual interview and at 3, 6 and 12 months, along with rating scale values from the Hospital Anxiety and Depression Scale, Rosenberg self-esteem scale, Schwarzer self-efficacy scale, a quality of life scale (SF-36) and the revised Skin Management Needs Assessment Checklist (Revised SMnac), which was used as the primary endpoint.ResultsTwenty patients were included in the study. The mean patient age was 52 years (SD: 9,8). Sixteen patients had traumatic spinal cord injuries, with a median injury duration of 234 months (IQR: 123–407). Seventy-five percent had had a pressure ulcer in the twelve months prior to the study. Patient education was shown to have a significant impact on skin management ability, with a highly significant increase in the overall revised SMnac score at 3 months. These results were stable over time, from 6 to 12 months. Six patients developed a pressure ulcer during the study (30%).ConclusionThis study supports the hypothesis that a therapeutic educational program conducted at the chronic phase in spinal cord injured individuals has an impact.     

The effect of pressure and shear on tissue viability of human skin in relation to the development of pressure ulcers: a systematic review

Pressure ulcers are a significant problem in health care, due to high costs and large impact on patients' life. In general, pressure ulcers develop as tissue viability decreases due to prolonged mechanical loading. The relation between load and tissue viability is highly influenced by individual characteristics. It is proposed that measurements of skin blood flow regulation could provide good assessment of the risk for pressure ulcer development, as skin blood flow is essential for tissue viability. . Therefore, the aim of this systematic review is to gain insight in the relation between mechanical load and the response of the skin and underlying tissue to this loading measured in-vivo with non-invasive techniques.A systematic literature search was performed to identify articles analysing the relation between mechanical load (pressure and/or shear) and tissue viability measured in-vivo. Two independent reviewers scored the methodological quality of the 22 included studies. Methodological information as well as tissue viability parameters during load application and after load removal were extracted from the included articles and used in a meta-analysis.Pressure results in a decrease in skin blood flow parameters, compared to baseline; showing a larger decrease with higher magnitudes of load. The steepness of the decrease is mostly dependent on the anatomical location. After load removal the magnitude of the post-reactive hyperaemic peak is related to the magnitude of pressure. Lastly, shear in addition to pressure, shows an additional negative effect, but the effect is less apparent than pressure on skin viability.     

Development and preliminary validation of a tool measuring concordance and belief about performing pressure-relieving activities for pressure ulcer prevention in spinal cord injury

ObjectiveTo develop and examine the reliability, and validity of a questionnaire measuring concordance for performing pressure-relief for pressure ulcer (PrU) prevention in people with Spinal Cord Injury (SCI).MethodsPhase I included item development, content and face validity testing. In phase II, the questionnaire was evaluated for preliminary acceptability, reliability and validity among 48 wheelchair users with SCI.ResultsThirty-seven items were initially explored. Item and factor analysis resulted in a final 26-item questionnaire with four factors reflecting concordance, perceived benefits, perceived negative consequences, and personal practical barriers to performing pressure-relief activities. The internal consistency reliability for four domains were very good (Cronbach's α = 0.75-.89). Pearson correlation coefficient on a test-retest of the same subjects yielded significant correlations in concordance (r² = 0.91, p = .005), perceived benefit (r² = 0.71, p < .04), perceived negative consequences (r² = 0.98, p < .0001), personal barriers (r² = 0.93, p= .002). Participants with higher levels of concordance reported a greater amount of pressure-relieving performed. Individuals viewing PrU as a threatening illness were associated with higher scores of concordance and tended to report a greater amount of pressure-relieving performance which provides evidence of criterion related validity.ConclusionThe new questionnaire demonstrated good preliminary reliability and validity in people with SCI. Further evaluation is necessary to confirm these findings using larger samples with follow-up data for predictive validity. Such a questionnaire could be used by clinicians to identify high risk of patients and to design individualised education programme for PrU prevention.     

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial

AimSub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS.Materials and methodsThis pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes.ResultsOf 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing.ConclusionsMost feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.     

A review of foot finite element modelling for pressure ulcer prevention in bedrest: Current perspectives and future recommendations

Pressure ulcers (PUs) are a major public health challenge, having a significant impact on healthcare service and patient quality of life. Computational biomechanical modelling has enhanced PU research by facilitating the investigation of pressure responses in subcutaneous tissue and skeletal muscle. Extensive work has been undertaken on PUs on patients in the seated posture, but research into heel ulcers has been relatively neglected. The aim of this review was to address the key challenges that exist in developing an effective FE foot model for PU prevention and the confusion surrounding the wide range of outputs reported. Nine FE foot studies investigating heel ulcers in bedrest were identified and reviewed. Six studies modelled the posterior part of the heel, two included the calf and foot, and one modelled the whole body. Due to the complexity of the foot anatomy, all studies involved simplification or assumptions regarding parts of the foot structure, boundary conditions and material parameters. Simulations aimed to understand better the stresses and strains exhibited in the heel soft tissues of the healthy foot. The biomechanical properties of soft tissue derived from experimental measurements are critical for developing a realistic model and consequently guiding clinical decisions. Yet, little to no validation was reported in each of the studies. If FE models are to address future research questions and clinical applications, then sound verification and validation of these models is required to ensure accurate conclusions and prediction of patient outcomes. Recommendations and considerations for future FE studies are therefore proposed.     

Direct variable cost of the topical treatment of stages III and IV pressure injuries incurred in a public university hospital

Aim

to estimate the direct variable costs of the topical treatment of stages III and IV pressure injuries of hospitalized patients in a public university hospital, and assess the correlation between these costs and hospitalization time.

The prevalence and prevention of pressure ulcers: A multicenter study of nine nursing homes in eastern China

AimTo assess the prevalence, related factors, and strategies for the prevention and treatment of pressure ulcers (PUs) in nursing homes in eastern China.Materials and methodsIn this cross-sectional multicenter survey, assessments of 1158 residents in nine nursing homes in eastern China were conducted on a single day in August of 2019.ResultsOf the 1158 residents, 56 (4.8%) had at least one PU. Most of the identified PUs were classified as stage 3 (39.3%) and developed at home (55.4%). By multiple regression analysis, eating mode, bed-bound, and Braden score were significant association with the development of PUs in nursing homes.ConclusionsThe prevalence of PUs in this study was similar to that reported by previous international studies. The implementation of measures for the prevention and treatment of PUs is insufficient in nursing homes in eastern China. Further, this study raised the issue of the lack of measures to prevent the development of PUs at home.     

The wound/burn guidelines – 2: Guidelines for the diagnosis and treatment for pressure ulcers

The Wound/Burn Guidelines Committee consists of members commissioned by the Board of Directors of the Japanese Dermatological Association (JDA). It held several meetings and evaluations in writing since October 2008, and drafted five guidelines for the diagnosis and treatment including commentaries on wounds in general and the Guidelines for the Diagnosis and Treatment for Pressure Ulcers by taking opinions of the Scientific Committee and Board of Directors of JDA into consideration.