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

Does prolotherapy have an effect on the care of pressure injuries? A pilot study

BACKGROUND

This study contributes to wound healing with prolotherapy in people with pressure injuries. The study was planned and conducted as a randomized controlled trial to determine the effect of prolotherapy on the care of pressure injuries.

METHODS

The study was carried out with patients with pressure injuries in the intensive care unit of a city hospital between April and June 2023. A power analysis was performed, and the sample size was calculated as 20 patients, including 10 in the intervention and 10 in the control group. The patients in the experimental group were given wound care with gelofusine as prolotherapy in the morning and evening for three days, and the injury site was covered with a sterile sponge and fixation tape. The patients in the control group were treated with saline in the morning and evening for three days. In both groups, the wound width, depth, and length were measured and evaluated prior to each intervention for three days.

RESULTS

In the study, a significant difference was found between the mean ages of the participants in the experimental and control groups (p < 0.05). The decrease in width measurements in the experimental group was found to be statistically significant compared to the previous measurements, while the increase in width measurements in the control group was significant compared to the previous measurements (p < 0.05). Depth measurements decreased statistically significantly in the experimental group, while they increased significantly in the control group compared to previous measurement values (p < 0.05).

CONCLUSION

In conclusion, it was determined that the administration of gelofusine for pressure injuries as prolotherapy in the experimental group may be more effective in wound healing than saline treatment applied in the control group. Further studies are warranted.

Transformative Insights into Community-Acquired Pressure Injuries Among the Elderly: A Big Data Analysis

PURPOSE

To investigate community-acquired pressure injuries (CAPIs) in older people by utilizing big data.

DESIGN

Retrospective data curation and analysis of inpatient data from two general medical centers between 1 January 2016 and 31 December 2018.

METHODS

Nursing assessments from 44,449 electronic medical records of patients admitted to internal medicine departments were retrieved, organized, coded by data engineers, and analyzed by data scientists. Potential explanatory patient characteristics tested were gender, age, admission indices, nursing assessments including CAPIs, CAPI type and location, vital signs, and the results of lab tests within the first 36 h of admission.

FINDINGS

Most CAPIs were located in the buttocks (56.9%), followed by the sacrum (11.8%), ankle (10.8%), trochanter (5.1%), and leg (3.9%). Tissue associated with CAPIs was described as necrotic, serotic, bloody, granolithic, epithelial, and infected. There were 31% of first-degree CAPIs, 41% second-degree, and 18% third-degree. Previously unacknowledged patient characteristics associated with CAPIs are as follows: age, oxygen use, intestinal function, the touch senses of heat and pain, albumin, RDW (red cell distribution width), and systolic blood pressure.

CONCLUSIONS

The novel indicators for CAPIs underscore the importance of data-driven approaches in detecting and preventing CAPIs in community care. These markers can detect and prevent pressure ulcers in the community, particularly among the elderly.

RELEVANCE FOR CLINICAL PRACTICE

Nursing management is called upon to integrate information about novel patient characteristics associated with CAPI into clinical practice. Assimilating the insights from this hospital nursing-led study into community nursing will enhance the safety and quality of care for the elderly.

Risk prediction tools for pressure injury occurrence: an umbrella review of systematic reviews reporting model development and validation methods

BACKGROUND

Pressure injuries (PIs) place a substantial burden on healthcare systems worldwide. Risk stratification of those who are at risk of developing PIs allows preventive interventions to be focused on patients who are at the highest risk. The considerable number of risk assessment scales and prediction models available underscores the need for a thorough evaluation of their development, validation, and clinical utility. Our objectives were to identify and describe available risk prediction tools for PI occurrence, their content and the development and validation methods used.

METHODS

The umbrella review was conducted according to Cochrane guidance. MEDLINE, Embase, CINAHL, EPISTEMONIKOS, Google Scholar, and reference lists were searched to identify relevant systematic reviews. The risk of bias was assessed using adapted AMSTAR-2 criteria. Results were described narratively. All included reviews contributed to building a comprehensive list of risk prediction tools.

RESULTS

We identified 32 eligible systematic reviews only seven of which described the development and validation of risk prediction tools for PI. Nineteen reviews assessed the prognostic accuracy of the tools and 11 assessed clinical effectiveness. Of the seven reviews reporting model development and validation, six included only machine learning models. Two reviews included external validations of models, although only one review reported any details on external validation methods or results. This was also the only review to report measures of both discrimination and calibration. Five reviews presented measures of discrimination, such as the area under the curve (AUC), sensitivities, specificities, F1 scores, and G-means. For the four reviews that assessed the risk of bias assessment using the PROBAST tool, all models but one were found to be at high or unclear risk of bias.

CONCLUSIONS

Available tools do not meet current standards for the development or reporting of risk prediction models. The majority of tools have not been externally validated. Standardised and rigorous approaches to risk prediction model development and validation are needed.

TRIAL REGISTRATION

The protocol was registered on the Open Science Framework ( https://osf.io/tepyk ).

Impact of the degree of synergy between patient and nurse perceptions on the clinical outcome of pressure injury prevention: a mixed-methods systematic review protocol

INTRODUCTION

Pressure injuries are a common and significant concern in clinical practice, often serving as a vital quality indicator. While (clinical) practice guidelines have been established to offer recommendations for mitigating hospital-acquired pressure injuries, adherence among stakeholders remains inconsistent. The subjective perceptions of stakeholders, such as patients and nurses, may impede adherence to pressure ulcer prevention guidelines, potentially reducing the effectiveness of these interventions. However, there is currently insufficient evidence to comprehensively understand this influence. Therefore, this review aims to offer a broader understanding of how the perspectives of patients and nurses engaged in pressure injury prevention affect the effectiveness of specific interventions for pressure ulcer management.

METHODS AND ANALYSIS

We will conduct a convergent, segregated mixed-methods systematic review and perform a narrative synthesis with a focus on evidence of the effectiveness of pressure injury prevention strategies and patient and nurse perceptions. Our search will encompass several databases, including the 'Centre for Reviews and Dissemination' (CRD) Database, Medline (via Ovid), CINAHL (via Ebsco) and Scopus (via Elsevier). Additionally, we will cross-check reference lists from all included systematic reviews. Two independent reviewers will screen titles, abstracts, and full texts and extract data from the included studies. The quality of methodology of systematic reviews will be assessed using 'A Measurement Tool to Assess Systematic Reviews-2' (AMSTAR 2) and the risk of bias using 'Risk of Bias in Systematic Reviews' (ROBIS). Qualitative studies will undergo critical appraisal using appropriate Joanna Briggs checklists. If it is feasible to pool data from included studies, we will synthesise them accordingly, using meta-analysis for quantitative reviews and meta-aggregation for qualitative studies. The results from both qualitative and quantitative analyses will be compared with derive new recommendations for healthcare practice aimed at enhancing the quality of care.

ETHICS AND DISSEMINATION

Ethical approval is not required due to the nature of this intended review. The results of this review will be disseminated through publications, reports and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023438792.

EffEctiveness of Prophylactic fOam dressings in the prevention of saCral pressure injuries in at-risk hospitalised patients: the EEPOC trial

BACKGROUND

Prophylactic dressings are increasingly used to prevent pressure injuries in hospitalised patients. However, evidence regarding the effectiveness of these dressings is still emerging. This trial aims to determine the clinical and cost-effectiveness of a prophylactic silicone foam border dressing in preventing sacral pressure injuries in medical-surgical patients.

METHODS

This is a multicentre, pragmatic, parallel group, randomised controlled trial. A sample size of 1320 was calculated to have >90% power to detect a 5% difference in the primary outcome at an alpha of 0.05. Adult patients admitted to participating medical-surgical wards are screened for eligibility: ≥18 years, admitted to hospital within the previous 36 h, expected length of stay of ≥24 h, and assessed high risk for hospital-acquired pressure injury. Consenting participants are randomly allocated to either prophylactic silicone foam dressing intervention or usual care without any dressing as the control group via a web-based randomisation service independent of the trial. Patients are enrolled across three Australian hospitals. The primary outcome is the cumulative incidence of patients who develop a sacral pressure injury. Secondary outcomes include the time to sacral pressure injury, incidence of severity (stage) of sacral pressure injury, cost-effectiveness of dressings, and process evaluation. Participant outcomes are assessed daily for up to 14 days by blinded independent outcome assessors using de-identified, digitally modified sacral photographs. Those who develop a sacral pressure injury are followed for an additional 14 days to estimate costs of pressure injury treatment. Analysis of clinical outcomes will be based on intention-to-treat, per-protocol, and sensitivity analyses.

DISCUSSION

This trial aims to provide definitive evidence on the effect prophylactic dressings have on the development of hospital-acquired sacral pressure injuries in medical-surgical patients. A parallel economic evaluation of pressure injury prevention and treatment will enable evidence-informed decisions and policy. The inclusion of a process evaluation will help to explain the contextual factors that may have a bearing on trial results including the acceptability of the dressings to patients and staff. The trial commenced 5 March 2020 and has been significantly delayed due to COVID-19.

TRIAL REGISTRATION

ANZCTR ACTRN12619000763145. Prospectively registered on 22 May 2019.

Interventions for the treatment and prevention of pressure ulcers

Pressure ulcers can affect multiple aspects of an individual's life. Though preventable, pressure ulcers place a substantial economic burden on healthcare services. Countries around the world have set pressure ulcer prevention and treatment as a high priority. National Clinical Guidelines recommend a wide range of preventative and curative treatments. However, there is still much uncertainty regarding the effectiveness of preventative and curative treatments. This overview of systematic reviews aims to describe the findings of 15 Cochrane reviews on the treatment and prevention of pressure ulcers included in a previous umbrella review and to expand upon their findings in the context of clinical practice.

Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The aim of the study was to investigate the effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings.

REVIEW METHOD USED

This is a systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Five databases (CINAHL, MEDLINE, Scopus, Web of Science, and Embase) were searched in mid-2019. Searches were updated (in April 2020) to year end 2019.

REVIEW METHODS

From an overarching systematic review and meta-analysis examining the effectiveness of pressure injury preventative interventions in adults admitted to acute hospital settings, trials conducted in intensive care were separated for an intensive care-specific synthesis. Two reviewers, with a third as an arbitrator, undertook study selection, data extraction, and risk-of-bias assessment. Included trials were grouped by intervention type for narrative synthesis and for random-effects meta-analysis using intention-to-treat data where appropriate.

RESULTS

Overall, 26 trials were included. Ten intervention types were found (support surfaces, prophylactic dressings, positioning, topical preparations, continence management, endotracheal tube securement, heel protection devices, medication, noninvasive ventilation masks, and bundled interventions). All trials, except one, were at high or unclear risk of bias. Four intervention types (endotracheal tube securement, heel protection devices, medication, and noninvasive ventilation masks) comprised single trials. Support surface trials were limited to type (active, reactive, seating, other). Meta-analysis was undertaken for reactive surfaces, but the intervention effect was not significant (risk ratio = 0.24, p = 0.12, I² = 51%). Meta-analyses demonstrated the effectiveness of sacral (risk ratio = 0.22, p < 0.001, I² = 0%) and heel (risk ratio = 0.31, p = 0.02; I² = 0%) prophylactic dressings for pressure injury prevention.

CONCLUSIONS

Only prophylactic sacral and heel dressings demonstrated effectiveness in preventing pressure injury in adults admitted to intensive care settings. Further intensive care-specific trials are required across all intervention types. To minimise bias, we recommend that all future trials are conducted and reported as per relevant guidelines and recommendations.

Knowledge of pressure injury in medical and surgical nurses in a tertiary level hospital: A cross-sectional study

BACKGROUND

Nurses play a vital role in pressure injury prevention (PIP) but require foundational knowledge to ensure appropriate PIP strategies are enacted.

AIMS

To describe and compare medical and surgical nurses' knowledge of pressure injury (PI) in a tertiary level hospital in China, and to identify predictors of PI knowledge among these groups.

DESIGN

A cross-sectional survey was conducted between June and December 2020.

METHODS

Registered nurses from nine medical and fifteen surgical wards in a tertiary hospital were invited. The survey was composed of two parts; demographic and professional characteristics; and the Chinese translated version of the Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT 2.0) where the total score ranged from 0 to 25; higher scores imply more knowledge. Medical and surgical nurses' knowledge test scores were compared using independent t-test. Multiple linear regression analysis was used to determine factors predictive of nurses' knowledge.

RESULTS

In total, 423 nurses from 24 wards participated the study and 404 nurses (95.5%) completed the knowledge test (Surgical n = 236, 58.4%; Medical n = 168, 41.6%). The PUKAT 2.0 mean score was 11.6 ± 3.0 (Surgical 12.2 ± 3.0; Medical 10.7 ± 2.8) with 335 (82.9%) nurses scoring <60%. Multiple linear regression showed working in surgical wards, nurse-in-charge position and previous PI training were significant predictors of knowledge scores.

CONCLUSION

Knowledge is a precursor to safe practice. Nurses demonstrated poor knowledge of PIP. Pressure injury related education may help improve nurses' knowledge but the extent to which it is used in place and impacts patients' outcome requires more investigation.

Repositioning for pressure injury prevention in adults: An abridged Cochrane systematic review and meta-analysis

BACKGROUND

A pressure injury is an area of localised damage to the skin and underlying tissues. Patient repositioning is an important prevention strategy, as those with limited mobility are at increased risk of developing pressure injury.

OBJECTIVES

To assess the clinical and cost-effectiveness of repositioning schedules on the prevention of pressure injury in adults.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials; MEDLINE (Ovid); Embase (Ovid) and Cumulative Index of Nursing and Allied Health Literature Plus (EBSCO) were searched in February 2019. No restrictions were applied to language or date of publication.

REVIEW METHODS

Studies were eligible if they were randomised controlled trials including cluster trials, published or unpublished, and undertaken in any healthcare setting that assessed the clinical and/or cost effectiveness of repositioning schedules for prevention of pressure injury in adults. Methodological quality of the studies was independently assessed by three authors. Heterogeneity between studies was assessed using the I² statistic, and the pooled risk ratios along with their 95% confidence intervals were estimated using either fixed and random effects models, as indicated. Grading of Recommendations Assessment, Development and Evaluation was used to appraise the certainty of evidence.

RESULTS

Eight eligible trials involving 3,941 participants published between 2004 and 2018 were identified. Trials compared either different repositioning frequencies or positioning regimens. Three trials (1074 participants) compared 2-hourly with 4-hourly repositioning (risk ratio 1.06, 95% confidence interval 0.80 to 1.41; I² = 45%). Two other trials (252 participants) compared a 30-degree tilt with a 90-degree tilt (risk ratio0.62, 95% confidence interval 0.10 to 3.97; I² =69%). Only two trials included economic analyses, both amongst nursing home residents. One study estimated the costs of repositioning to be Canadian dollars $11.05 and Canadian dollars $16.74 less per resident per day for the 3-hourly or 4-hourly regimens, respectively, when compared to 2-hourly regimen. The second study reported 3-hourly repositioning using a 30-degree tilt to cost €46.50 (95% confidence interval €1.25 to €74.60) less per patient in nursing time compared with 6-hourly repositioning with a 90-degree lateral rotation.

CONCLUSION

It remains unclear which repositioning frequencies or positions are most effective in preventing pressure injury in adults. There is limited evidence to support the cost effectiveness of repositioning frequencies and positions. Registration: Cochrane protocol published in 2012.