Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial

Evaluation of Shear Force Redistribution and Microclimate in Foam Dressings Indicated for Pressure Injury Prevention

OBJECTIVE

To understand the performance of a border and silicone version of a next-generation multilayered foam dressing (dressings A and B) compared with three commercially available wound dressings (dressings C, D, and E) in bench tests relevant for pressure injuries.

METHODS

Two methods were used. The first measured shear force transmission through dressings in low- and high-shear force scenarios compared with a control with no dressing. The second measured the dressings' microclimate (heat and moisture) compared with two controls: one with high moisture output and one with no moisture output. Statistical significance was determined using a 95% CI and t test with α = .05.

RESULTS

In the low-shear scenario, dressing A showed the lowest force transmission, whereas dressing B was not significantly different from dressings C and E. In the high-shear scenario, dressing D had a significantly higher percentage of transmitted forces compared with the other dressings, with dressing A showing the lowest force transmission but no significant differences among the other three dressings. Regarding microclimate, dressing A showed no significant difference in relative humidity in the dressing-indenter and dressing-surface interfaces, suggesting good breathability. Dressing E had the highest temperature at the indenter-dressing interface, significantly different from the other dressings ( P < .05).

CONCLUSIONS

The study found that a next-generation foam dressing (dressing A) had better breathability and lower shear force transmission than other available dressings. This study emphasized the importance of understanding the physical properties of dressings to choose the most appropriate product based on individual patient needs, wound characteristics, and environmental conditions.

Pressure Distribution Properties in Wound Dressings Using Heel and Sacrum Indenters Under Clinically Relevant Loads

OBJECTIVE

To understand the pressure distribution characteristics of a border and silicone version of a next-generation multilayered foam dressing (A and B) compared with three commercially available dressings (C, D, and E) using a novel pressure distribution model with clinically relevant pressures.

METHODS

The testing setup included a support surface analog of K45 foam covered with polyurethane fabric, a high-resolution pressure mapping system, and a silicone layer to simulate overlying tissue. The dressing was exposed to clinically relevant loads of 30 and 80 mm Hg for 60 seconds using new sacral and heel indenters. A control was conducted using the same setup without a dressing. Statistical significance was determined using a 95% CI and t test with α = .05.

RESULTS

All dressings decreased pressure and increased contact area compared with the control ( P < 0.05). Dressings A and B had lower peak pressures than dressings C and E for both indenters. Dressings D and B had the largest contact areas and lowest pressures in the heel indenters, whereas dressing E had the smallest contact area and the highest pressures for both indenters. The results also demonstrated a strong negative correlation between the average pressure and the contact area for both indenters.

CONCLUSIONS

Using anatomically accurate indenters and clinically relevant pressures, the study demonstrated that dressings A and B significantly reduced interface pressure compared with no dressing, suggesting potential advantages for pressure redistribution in vulnerable areas. Additional clinical research in various care settings is needed to validate this study's findings.

Application of pressure injury preventive measures and bundles in home and community environments: a scoping review protocol

INTRODUCTION

Several studies have addressed the use of pressure injury preventive measures and bundles for hospitalised patients. However, there is a gap in research regarding the use of pressure injury preventive measures and bundles in the home environment. This scoping review aims to identify, explore and map the international literature on pressure injury preventive measures and bundles in the home and community environments.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will be used to guide the reporting of this scoping review. The Joanna Briggs Institute guide will inform the methods. A modified version of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols will be used to guide the reporting of this scoping review protocol. An initial search was carried out in July 2024. The search will be conducted in electronic databases such as LILACS, SciELO, Scopus, PubMed, Embase, CINAHL, Cochrane Library and Web of Science. The search will be restricted to studies in English, Portuguese and Spanish, with no time restriction. Additional literature will be retrieved by reviewing the reference lists of the selected studies based on their titles. Two independent reviewers will carry out the data extraction process. Essential details, including the author, references and findings pertinent to the review questions, will be collected. The findings will be displayed through graphs, tables and figures, supplemented by a narrative summary.

ETHICS AND DISSEMINATION

As this review will be conducted using secondary data, ethical approval is not required. Results will be shared with the international scientific community through conference presentations and publication in a high-impact journal.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework registry (osf.io/m5gvn) on 8 August 2024.

Advanced biomaterials in pressure ulcer prevention and care: from basic research to clinical practice

Pressure ulcers are a common and serious medical condition. Conventional treatment methods often fall short in addressing the complexities of prevention and care. This paper provides a comprehensive review of recent advancements in advanced biomaterials for pressure ulcer management, emphasizing their potential to overcome these limitations. The study highlights the roles of biomaterials in enhancing wound healing, preventing infections, and accelerating recovery. Specific focus is placed on the innovation and application of multi-functional composite materials, intelligent systems, and personalized solutions. Future research should prioritize interdisciplinary collaboration to facilitate the clinical translation of these materials, providing more effective and tailored treatment approaches. These advancements aim to improve the quality of life and health outcomes for patients by offering more reliable, efficient, and patient-specific therapeutic options.

Dressings and topical agents for preventing pressure ulcers

BACKGROUND

Pressure ulcers occur when people cannot reposition themselves to relieve pressure over bony prominences. They are difficult to heal, costly, and reduce quality of life. Dressings and topical agents (lotions, creams, and oils) for pressure ulcer prevention are widely used. However, their effectiveness is unclear. This is the third update of this review.

OBJECTIVES

To evaluate the effects of dressings and topical agents on pressure ulcer prevention, in people of any age without existing pressure ulcers, but at risk of developing one, in any healthcare setting.

SEARCH METHODS

We used the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, two other databases, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify the studies that are included in the review. The latest search date was November 2022. We imposed no restrictions on language, publication date, or setting.

SELECTION CRITERIA

We included randomised controlled trials that enroled people at risk of developing a pressure ulcer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

In this update, we added 33 new studies, resulting in a total of 51 trials (13,303 participants). Of these, 31 studies involved dressings, 16 topical agents, and four included both dressings and topical agents. All trials reported the primary outcome of pressure ulcer incidence. Dressings Pressure ulcer incidence We made a total of 13 comparisons with 9027 participants. We present seven prioritised comparisons in the summary of findings (SoF) tables, as follows: silicone foam dressing versus no dressing (18 trials, 5903 participants; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.33 to 0.77); foam dressing versus film dressing (3 trials, 569 participants; RR 0.72, 95% CI 0.20 to 2.67); hydrocellular foam dressing versus hydrocolloid dressing (1 trial, 80 participants; RR not estimable); silicone foam dressing type 1 versus silicone foam dressing type 2 (2 trials, 376 participants; RR 0.80, 95% CI 0.56 to 1.15); foam dressing versus fatty acid (2 trials, 300 participants; RR 1.67, 95% CI 0.49 to 5.72); polyurethane film versus hydrocolloid dressing (1 trial, 160 participants; RR 0.58, 95% CI 0.24 to 1.41); and hydrocolloid dressing versus no dressing (2 trials, 230 participants; RR 0.60, 95% CI 0.46 to 0.78). All low or very low-certainty evidence. The evidence is very uncertain about the effect of dressings on pressure ulcer development. Pressure ulcer stage Three comparisons reported pressure ulcer (PU) stage. Silicone foam dressing versus no dressing: PU stage 1 (8 trials, 1823 participants; RR 0.32, 95% CI 0.13 to 0.79); PU stage 2 (10 trials, 2873 participants; RR 0.47, 95% CI 0.30 to 0.73); PU stage 3 (3 trials, 718 participants; RR 0.45, 95% CI 0.06 to 3.21); PU stage 4 (2 trials, 610 participants; RR 0.21, 95% CI 0.02 to 1.77); unstageable PU (1 trial, 366 participants; RR 0.20, 95% CI 0.01 to 4.09); deep tissue injury (3 trials, 840 participants; RR 0.32, 95% CI 0.09 to 1.08). Foam dressing versus film dressing: PU stage 1 (1 trial, 270 participants; RR 0.56, 95% CI 0.39 to 0.80); PU stage 2 (1 trial, 270 participants; RR 1.00, 95% CI 0.06 to 15.82); deep tissue injury (1 trial, 270 participants; RR 0.67, 95% CI 0.11 to 3.93). Hydrocolloid dressing versus no dressing: PU stage 1 (1 trial, 108 participants; RR 0.54, 95% CI 0.31 to 0.94); PU stage 2 (1 trial, 108 participants; RR 0.86, 95% CI 0.28 to 2.66). All low or very low-certainty evidence. The evidence is very uncertain about the effect of dressings on different stages of pressure ulcer development. Adverse events One comparison reported adverse events: silicone foam dressing versus no dressing (3 trials, 2317 participants; RR not estimable; very low-certainty evidence). Silicone foam dressings may have little to no effect on the incidence of adverse events, but the evidence is very uncertain. Topical agents Pressure ulcer incidence We evaluated seven comparisons with 4276 participants. We present five prioritised comparisons in the SoF tables as follows: fatty acid versus placebo (6 trials, 2201 participants; RR 0.86, 95% CI 0.54 to 1.36); fatty acid versus usual care (7 trials, 1058 participants; RR 0.64, 95% CI 0.46 to 0.84); cream versus fatty acid (1 trial, 120 participants; RR 3.00, 95% CI 0.32 to 28.03); cream versus placebo (3 trials, 513 participants; RR 1.18, 95% CI 0.59 to 2.36); and cream versus usual care (1 trial, 47 participants; RR 1.60, 95% CI 0.84 to 3.04). All very low-certainty evidence. It is very uncertain whether they make any difference to PU development. Pressure ulcer stage Two comparisons reported PU stage. Fatty acid versus usual care: PU stage 1 (2 trials, 180 participants; RR 1.00, 95% CI 0.49 to 2.03); PU stage 2 (2 trials, 180 participants; RR 0.19, 95% CI 0.07 to 0.53). Cream versus placebo: PU stage 3 (1 trial, 258 participants; RR 1.25, 95% CI 0.34 to 4.55); PU stage 4 (1 trial, 258 participants; RR 0.33, 95% CI 0.01 to 8.11). Both low or very low-certainty evidence. It is uncertain whether they make any difference to the stage of PU development. Adverse events One comparison reported adverse events: fatty acid versus placebo (3 trials, 967 participants; RR 4.38, 95% CI 0.50 to 38.30; very low-certainty evidence). Fatty acid may have little to no effect on the incidence of adverse events compared to placebo, but the evidence is very uncertain. Risk of bias and imprecision were the main reasons for downgrading the certainty of the evidence.

AUTHORS' CONCLUSIONS

The included studies tested a wide variety of dressings and topical agents. The evidence for all interventions is uncertain or very uncertain; thus, it is unclear whether any of the dressings or topical agents studied make any difference to pressure ulcer development. Future studies should engage with stakeholders to determine priority interventions.

Economic Evaluation of Multilayer Silicone-Adhesive Polyurethane Foam Dressing for the Prevention of Pressure Ulcers in at-risk Hospitalized Patients: US and Italian Perspective

BACKGROUND

Hospital-acquired pressure ulcers (HAPUs) constitute an important source of concern for healthcare systems due to their negative consequences on patient quality of life and hospital costs. This phenomenon is increasing worldwide, driven by an aging population and increasing prevalence of chronic conditions. This economic evaluation aimed to determine whether using a multilayer, silicone-adhesive polyurethane foam dressing shaped for the sacrum area, alongside standard prevention (SP), is cost-effective in preventing HAPUs for hospitalized patients compared to SP alone.

METHODS

We developed a decision-analytic model to estimate the expected costs and clinical benefits of using the polyurethane foam dressing from Italian and US payor perspectives. Model inputs were taken from published studies, and uncertainty was assessed using one-way and probabilistic sensitivity analyses (PSA).

RESULTS

From both US and Italian perspectives, using a foam dressing in addition to SP was found to be cost-saving in all hospital settings. That is, it reduced the incidence of HAPUs at a lower cost overall. The estimated savings were €179 per patient and $305 per patient from Italian and US perspectives. Following sensitivity analysis, the results remained cost-saving, suggesting that our findings are robust.

CONCLUSION

This is the first economic analysis investigating the cost-effectiveness of preventive dressings and standard prevention for avoiding sacral pressure ulcers for at-risk hospitalized patients. This analysis suggests that using a multilayer polyurethane foam dressing to prevent sacral HAPUs in at-risk hospitalized patients is a cost-effective strategy compared with standard prevention alone and, therefore, should be considered as a strategy for PU prevention in hospital settings.

The frictional energy absorber effectiveness and its impact on the pressure ulcer prevention performance of multilayer dressings

Pressure ulcers including heel ulcers remain a global healthcare concern. This study comprehensively evaluates the biomechanical effectiveness of the market-popular ALLEVYN® LIFE multilayer dressing in preventing heel ulcers. It focuses on the contribution of the frictional sliding occurring between the non-bonded, fully independent layers of this dressing type when the dressing is protecting the body from friction and shear. The layer-on-layer sliding phenomenon, which this dressing design enables, named here the frictional energy absorber effectiveness (FEAE), absorbs approximately 30%-45% of the mechanical energy resulting from the foot weight, friction and shear acting to distort soft tissues in a supine position, thereby reducing the risk of heel ulcers. Introducing the novel theoretical FEAE formulation, new laboratory methods to quantify the FEAE and a review of relevant clinical studies, this research underlines the importance of the FEAE in protecting the heels of at-risk patients. The work builds on a decade of research published by our group in analysing and evaluating dressing designs for pressure ulcer prevention and will be useful for clinicians, manufacturers, regulators and reimbursing bodies in assessing the effectiveness of dressings indicated or considered for prophylactic use.

Association of Spinal Alignment and Abdominal Circumference with Sarcopenia Status and Fall Risk in Patients with Osteoporosis: A Retrospective Study

Since vertebral kyphosis and abdominal circumference are thought to influence sarcopenia and fall risk in osteoporosis, we evaluated sarcopenia and fall risk in patients with different measurements of abdominal circumference and sagittal longitudinal axis (SVA). In this post hoc study, 227 patients aged 65 years or more who visited an outpatient osteoporosis clinic were included in the analysis. Sarcopenia was determined from lean body mass, grip strength, and walking speed by dual energy X-ray absorptiometry; SVA (median 40 mm) and abdominal circumference (median 80 cm) were compared between the four groups, each divided into two groups. Nutritional management, falls, and fall anxiety scores were also examined. The incidence of sarcopenia was significantly increased in those with abdominal circumference < 80 cm in both the SVA < 40 mm and SVA ≥ 40 mm groups (p < 0.05). Nonetheless, the fall scores of those with SVA < 40 mm were lower than those of individuals with SVA ≥ 40 mm (p < 0.01). Based on the results of this study, SVA and abdominal circumference values may predict the risk of sarcopenia and falls. More research is needed before our results can be translated into clinical practice.

Effect of a prophylactic dressing for sacral pressure injuries in non-critically ill patients after general surgery: A randomized controlled trial

BACKGROUND

Hospital-acquired pressure injuries are strongly associated with surgeries performed under general anesthesia.

AIMS

The aim of this study was to evaluate the effects of using a prophylactic multi-layer soft silicone foam dressing in non-critically ill patients with a Braden Scale score of ≤18 after undergoing routine surgery without sacral pressure injuries.

METHODS

This randomized controlled trial included 156 patients who were admitted for surgery under general anesthesia in a tertiary general hospital. The patients were divided into a control group and an intervention group. A 5-layer soft silicone foam dressing was applied to the sacrum of patients in the intervention group immediately after surgery. For the control group, standard pressure injury prevention activities were performed alongside standard care without preventive dressings.

RESULTS

There were no significant differences in general and clinical characteristics between the two groups; however, the incidence of pressure injury and blanching erythema was higher in the control group, showing a significant difference from the experimental group. Factors influencing the development of pressure injuries and blanching erythema through multivariate regression analysis were prophylactic dressing application and Braden Scale score at the time of admission. A statistically significant difference was noted in survival time from pressure injury between both groups.

LINKING EVIDENCE TO ACTION

The incidence of pressure injuries and blanching erythema was lower when the prophylactic dressing was applied with standard protocol for general ward patients after surgery. Accurate evaluation of the patient's skin condition and pressure injury risk assessment before surgery are important. Progressive prophylactic dressings to prevent pressure injuries are effective, and tailored nursing interventions based on accurate assessment of patient's skin condition and risk factors are essential for maintaining skin integrity.

The Effect of Prophylactic Silicone Dressings on the Incidence of Pressure Injuries on Patients in the Acute Care Setting: A Systematic Review and Meta-analysis

PURPOSE

To explore the effect of silicone dressings on the prevention of pressure injuries in patients cared for in the acute care setting. Three main comparisons were explored: silicone dressing versus no dressing, all anatomical areas; silicone dressing versus no dressing on the sacrum; and silicone dressing versus no dressing on the heels.

METHODS

Using a systematic review methodology, published randomized controlled trials and cluster randomized controlled trials were included. The search was conducted from December 2020 to January 2021 using CINAHL, full text on EBSCOhost, MEDLINE on EBSCOhost, and Cochrane databases. The search returned 130 studies; 10 met inclusion criteria. Data were extracted using a predesigned extraction tool. The Cochrane Collaboration tool was used to assess the risk of bias and the certainty of the evidence was appraised using a software program specifically designed for this purpose.

RESULTS

Silicone dressings probably reduce the incidence of pressure injuries compared to no dressings (relative risk [RR]: 0.40, 95% confidence interval [CI]: 0.31-0.53; moderate certainty evidence). Furthermore, silicone dressings probably reduce the incidence of pressure injuries on the sacrum compared to no dressings (RR: 0.44, 95% CI: 0.31-0.62; moderate certainty evidence). Finally, silicone dressings probably reduce the incidence of pressure injuries on the heels compared to no dressings (RR: 0.44, 95% CI: 0.31-0.62; moderate certainty evidence).

CONCLUSION

There is moderate certainty evidence of the effect of silicone dressings as a component of a pressure injury prevention strategy. The main limiting factor in the study designs was a high risk of performance and detection bias. Although this is a challenge to achieve in trials such as these, consideration should be given to how the effect of this could be minimized. A further issue is the lack of head-to-head trials that limits clinicians' abilities to determine whether any of the products in this category are more effective than others.

Quality of life in postmenopausal women with osteoporosis: a systematic review and meta-analysis

PURPOSE

Postmenopausal osteoporosis has become a global trend, which seriously affects women's quality of life. However, the differences remain unclear in health-related quality of life (HRQoL) among postmenopausal women with normal bone mineral density, osteoporosis, and osteoporotic fractures. The aim of this study was to assess health-related quality of life in women with three different bone states.

METHODS

Databases of PubMed, Embase, Cochrane, and Web of Science were based on the search terms, and the search time was set from the inception of each database to January 2022. A study was included if the researchers used a validated quality of life questionnaire to investigate the quality of life of postmenopausal women with osteoporosis or osteoporotic fractures. The random-effect model was used for meta-analysis, and the mean difference with a 95% confidence interval (95%CI) was calculated.

RESULTS

Thirteen studies that met the inclusion criteria were systematically reviewed, involving 2897 postmenopausal women, and 12 of them were included in the meta-analysis. Postmenopausal women with osteoporosis had worse overall HRQoL and different HRQoL dimensions compared with postmenopausal women with normal bone density. Compared with postmenopausal women with osteoporosis, postmenopausal women with osteoporotic fractures had worse overall HRQoL and individual dimensions of HRQoL, especially physical component summary (SMD = - 0.61, 95% CI, - 0.98 to - 0.24). Bone mineral density was positively associated with HRQoL, while fragility fracture severity was negatively associated with HRQoL.

CONCLUSIONS

Postmenopausal osteoporosis and fragility fractures reduce HRQoL to varying degrees in women. More research should be done to reduce the incidence of the disease.

Prophylactic sacral protective dressings' effect on preventing pressure injury: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic sacral protective dressings on preventing pressure injury. A systematic literature search up to July 2021 was performed, and 11 studies included 5150 community or hospital-based adult subjects requiring care at the start of the study; 2832 of them were using sacral protective dressings and 2318 were given standard care with no sacral protective dressings. They were reporting relationships between the effects of prophylactic sacral protective dressings on preventing pressure injury. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effects of prophylactic sacral protective dressings on preventing pressure injury using the dichotomous method with a random or fixed-effect model. Sacral protective dressings had a significantly lower incidence of pressure injuries (OR, 0.39; 95% CI, 0.28-0.53, P < .001) compared with standard care with no sacral protective dressings in community- or hospital-based adult subjects requiring care. Sacral protective dressings had a significantly lower incidence of pressure injuries compared with standard care with no sacral protective dressings in community- or hospital-based adult subjects requiring care. Further studies are needed to confirm these findings.

Use of a Sacral Foam Dressing to Prevent Pressure Injury in At-Risk Subacute Hospitalized Older Adults: A Pilot Randomized Controlled Trial

PURPOSE

The purpose of this pilot study was to inform a future trial aimed at comparing the effectiveness of a prophylactic sacral dressing plus standard care to standard care only to reduce sacral pressure injuries (PIs) in at-risk older adults admitted to a subacute hospital setting.

DESIGN

A pilot study with a pragmatic, open-label, randomized controlled trial design.

SAMPLE AND SETTING

One hundred thirty participants were randomized (intervention n = 66, 50.8%; control n = 64, 49.2%). Protocol violations occurred in 48 participants (intervention n = 33, 68.8%; control n = 15, 31.3%). The study setting was a subacute hospital inpatient care unit located in Queensland, Australia.

METHODS

Participants were randomly allocated 1:1 to the intervention (prophylactic dressing plus standard care) or control group (standard care). Standard care included regular PI risk and skin assessments, and selection and implementation of preventive interventions (eg, support surfaces and increased repositioning) from a PI prevention care plan. The sacral dressing was applied for intervention participants immediately following recruitment. Ward and research staff collected data and assessed skin integrity daily; participants were followed up until onset of a PI or up to 28 days without PI occurrence. In addition, retrospective chart reviews were undertaken to verify PI occurrences. Patient comfort and dressing utility were also evaluated.

RESULTS

Two (3.0%) participants in the intervention group and 1 (1.6%) in the control group developed a sacral PI. The difference was not statistically significant. Only 1 PI was recorded prospectively, while 2 PIs were identified via retrospective chart review. Participants rated dressing comfort highly, particularly during the first 2 weeks, and nurses rated utility highly. Based on the intention-to-treat results, a sample size of 1799 per arm would be required in a definitive trial.

CONCLUSIONS

A definitive trial is feasible and warranted. However, the large sample size required in a definitive trial indicates the need for multiple sites.

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.

Risk factors for pressure ulcers in adult patients: A meta-analysis on sociodemographic factors and the Braden scale

AIMS AND OBJECTIVES

Providing the first meta-analysis of risk factors for pressure ulcer development in adult patients.

BACKGROUND

Pressure ulcers remain a serious health complication for patients and nursing staff. However, there is a lack of statistical evidence for risk factors as previous research did not include any quantitative synthesis.

DESIGN

Meta-analysis, using PRISMA guidelines.

METHODS

Studies from PubMed, Embase, CINAHL Complete, Web of Science, Cochrane Library, and other reviews and sources were screened and checked against the inclusion criteria. The risk of bias was evaluated using a slightly modified QUIPS tool. Data regarding population, design, statistical analysis and risk factors were extracted. Meta-analysis with comparable studies was conducted for age, sex, and Braden scale. The sub-group analysis was used to account for heterogeneity.

RESULTS

28 studies with 570,162 patients were entered in meta-analysis. Older age and a low total Braden scale score increased the risk for pressure ulcers. All subscales excluding 'moisture' reached significance in meta-analysis based only on few studies, however, limiting overall evidence. Male sex achieved mixed results, too.

CONCLUSION

The first meta-analytic analysis shows evidence for age and Braden scale as risk factors for pressure ulcer development. Limitations regarding study quality and heterogeneity must be considered, highlighting the need for unifying certain conditions in risk factor research.

RELEVANCE TO CLINICAL PRACTICE

Patients at risk for new pressure ulcers can be identified by their total Braden score and age, whereas the latter is also connected to deeper pressure ulcers. Nurses and health personnel should pay great attention to patients in older age and undergo specific training to utilise and evaluate the Braden scale effectively, if necessary.

Risk Factors for Pressure Injuries in Adult Patients: A Narrative Synthesis

Pressure injuries remain a serious health complication for patients and nursing staff. Evidence from the past decade has not been analysed through narrative synthesis yet. PubMed, Embase, CINAHL Complete, Web of Science, Cochrane Library, and other reviews/sources were screened. Risk of bias was evaluated using a slightly modified QUIPS tool. Risk factor domains were used to assign (non)statistically independent risk factors. Hence, 67 studies with 679,660 patients were included. In low to moderate risk of bias studies, non-blanchable erythema reliably predicted pressure injury stage 2. Factors influencing mechanical boundary conditions, e.g., higher interface pressure or BMI < 18.5, as well as factors affecting interindividual susceptibility (male sex, older age, anemia, hypoalbuminemia, diabetes, hypotension, low physical activity, existing pressure injuries) and treatment-related aspects, such as length of stay in intensive care units, were identified as possible risk factors for pressure injury development. Health care professionals' evidence-based knowledge of above-mentioned risk factors is vital to ensure optimal prevention and/or treatment. Openly accessible risk factors, e.g., sex, age, BMI, pre-existing diabetes, and non-blanchable erythema, can serve as yellow flags for pressure injury development. Close communication concerning further risk factors, e.g., anemia, hypoalbuminemia, or low physical activity, may optimize prevention and/or treatment. Further high-quality evidence is warranted.

Polyurethane foam dressings ameliorating local adverse effects of azacitidine: a randomized controlled trial

This study investigated the use of polyurethane foam dressings to prevent local adverse reactions of subcutaneous azacitidine injection. Patients receiving a subcutaneous azacitidine injection were randomly divided into experimental and control groups. A total of 55 patients were included in each group. A polyurethane foam dressing was used to cover the injection site of patients in the experimental group. Conventional treatment was used in the control group. Injection site pain and local skin reactions were assessed after the intervention in both groups. The score and duration of pain, the incidence and duration of local skin adverse reactions, and the incidence of severe reactions in the experimental group were significantly lower than in the control group (p < 0.05). Polyurethane foam dressing can effectively reduce local adverse reactions of subcutaneous injection of azacitidine, relieve pain, shorten the duration of local pain and adverse reactions, and improve the quality of nursing.

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

BACKGROUND

Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination.

OBJECTIVE

Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019.

METHODS

Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data.

RESULTS

Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I² = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I² = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I² = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I² = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I² = 36%).

CONCLUSIONS

Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number:CRD42019129556.

Use of multilayer silicone foam dressings as adjuvant therapy to prevent pressure injuries

Despite progress in the prevention of pressure injuries (PIs), they remain a challenging public health problem because of their frequency and morbidity. Protection of the skin by multilayer silicone foam dressings may be an adjuvant measure to prevent PIs in high-risk patients. Despite the available clinical data and published recommendations on this measure, caregivers face difficulties in identifying patients who would benefit from this adjuvant measure. The objective of this work was to define the profiles of high-risk patients who would benefit optimally from this measure in combination with basic preventive procedures. This consensual expert opinion was drawn up using two methods: the Nominal Group Technique with eight medical and paramedical experts, and the Delphi process with 16 experts. The bases for this expert consensual opinion were a formal search and analysis of the published literature regarding evidence on the prevention of PIs using multilayer silicone foam dressings. The consensual expert opinion reported here addresses five proposals mostly intended to define patients who would benefit from the use of a multilayer silicone foam dressing (≥4 layers) to prevent PIs (sacrum and heels).

Diagnosis and treatment impacts on wound care efficiency drivers: real-world analysis

Objective: The prevalence and economic burden of wounds are growing. Any wound has the potential to become hard-to-heal and require frequent care. Clinicians need to find ways to absorb demand on services without compromising outcomes. Drivers of wound care efficiency-time-to-heal, frequency of dressing change and the incidence of complications-can be evaluated to shape future wound management. A survey of wound care was conducted by clinicians from five centres in Sweden over a one-week period, during which clinicians documented every wound once. At the time of surveying, 49% of wounds were considered to be improving, infection incidence was 11.7% and dressings were changed a mean of 2.2 times per week, with highly exuding wounds changed 6.9 times per week. The data highlighted the importance of diagnosing patient and wound characteristics in selecting treatments and organising care. Recognised gaps in diagnoses potentially identify opportunities to influence healing, complication incidence and intensity of nursing, thus reducing demand on resources. In conclusion, this survey highlights opportunities to reduce the burdens these drivers present. Through improved diagnosis and alignment to recognised care pathways, there is potential to improve patient outcomes and alleviate the strains placed upon wound care providers.

Dressings for preventing pressure ulcers: how do they work?

Pressure ulcers (PUs) negatively affect quality of life (QoL) and cause problems for patients, such as pain, distress and often specific difficulties with treatments used to manage the wound. Thus, it is important to implement appropriate prevention strategies in order to achieve high-quality care, thereby reducing the burden of PUs on patients, the healthcare system and society as a whole. PU development arises due to the adverse effects of pressure, shear, friction and moisture at the skin/surface interface. Preventive interventions typically include risk assessment, reducing pressure and minimising shear and friction. More recently, certain wound dressings, as a potential additional protective strategy for preventing PUs, have been introduced. This review explores the mechanisms of action of dressings for preventing PUs. Findings from the review indicate that decreasing frictional forces transmitted to the patient's skin is achieved by use of a dressing with an outer surface made from a low friction material. Furthermore, the ability of dressings to absorb and redistribute shear forces through good adhesion to the skin, high loft and lateral movement of the dressing layers is important in reducing shear forces. This is achieved when the dressing reduces pressure transmitted to the patient's tissues by the propriety of high loft/thickness and padding that allows a degree of cushioning of bony prominences. Further, dressings may reduce humidity at the skin/dressing interface, i.e., the dressing is absorbent and/or permits moisture to evaporate quickly. As part of an established PU prevention protocol, dressings may help decrease PU incidence.

Comparison of polyurethane foam dressing and hydrocolloid dressing in patients with pressure ulcers: A randomized controlled trial protocol

BACKGROUND:

We conduct this randomized controlled trial protocol for the comparison of the influence of the hydrocolloid dressing and polyurethane foam dressing in the treatment of pressure ulcers (PUs) patients.

METHODS:

This study will be implemented from February 2021 to February 2022 at Hangzhou Geriatric Hospital. The experiment was granted through the Research Ethics Committee of Hangzhou Geriatric Hospital (C5259033). Criteria for inclusion: patients older than 18 years of age who have been diagnosed with PU. If the patient suffers from more than a PU, only the ulcer with largest diameter is evaluated. Criteria for exclusion: (1).. hypersensitivity or allergy to the substances in dressings; (2).. patients with diabetic foot or venous ulcers; and (3).. serious disease. The major result is rate of PU healing or ulcer epithelialization tissue. The secondary result is the changes in the area of ulcer in cm and cost-effectiveness. The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY).

RESULTS:

Table 1 will show the comparison of clinical outcomes between 2 groups.

CONCLUSION:

This study can develop an evidence-based protocol to identify optimal dressings for patients with PUs.

TRIAL REGISTRATION NUMBER:

researchregistry6294

Clinical and Economic Impact of Wound Care Using a Polyurethane Foam Multilayer Dressing

OBJECTIVE

To study the impact of a newly introduced dressing on efficiency and quality of care in routine clinical practice in a Spanish community setting.

DESIGN AND SETTING

An ambispective multicenter observational study was conducted in 24 primary care centers and 6 nursing homes in 4 different Spanish regions. The study was carried out between November 2017 and March 2019.

PATIENTS AND INTERVENTION

A total of 128 wounds in 94 patients (primary care, n = 79; nursing home, n = 15) were analyzed before and 4 weeks after switching to the study dressing.

OUTCOME MEASURES

Frequency of dressing changes; secondary outcomes were change in the mean wound area and weekly cost and patient and provider satisfaction.

MAIN RESULTS

The mean number of dressing changes was significantly reduced with the study dressing from 3.14 ± 1.77 changes per week to 1.66 ± 0.87 (P < .001), a 47.1% reduction in frequency. Wound area significantly reduced from 9.90 ± 19.62 cm to 7.10 ± 24.33 cm. In addition, a 58.7% reduction in weekly costs was achieved with the intervention. Patients and providers agreed that their satisfaction with wound care improved.

CONCLUSIONS

The use of the study dressing in routine clinical practice could lead to a major improvement in both efficiency and quality of wound care. Its use could reduce wound care-related costs through improvements in healing and a reduced frequency of dressing changes. It also enhanced the wound care experience from the perspective of both patients and providers.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background

Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs).

Objectives

To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone.

Methods

This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At‐risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) – pooled as the treatment group – and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites.

Results

In the intention‐to‐treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41–0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35–0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34–1·68, P = 0·49).

Conclusions

Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at‐risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

What is already known about this topic?

The incidence of hospital‐acquired pressure ulcers (PUs) remains high despite the implementation of best‐practice recommendations.

The concept of using silicone foam dressings as an additional prophylactic strategy in PU prevention has been investigated in previous studies but with some limitations.

Most RCTs were monocentric studies, restricted to either critically ill or acute care patients and did not observe more than two anatomical at‐risk skin sites, which limited the generalizability of the findings.

What does this study add?

This large pragmatic RCT suggests that it is beneficial to use silicone adhesive multilayer foam dressings on the sacrum, in addition to standard of care, to help prevent hospital‐acquired PUs.

Clinical decision making for heel dressings should be based on the clinical effectiveness of the intervention weighed against the potential risk of falling.

Linked Comment: F. Coyer. Br J Dermatol 2021; 185:4–5.

Effectiveness of Multilayered Polyurethane Foam Dressings to Prevent Hospital-Acquired Sacral Pressure Injuries in Patients With Hip Fracture: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to determine the effectiveness of a multilayered polyurethane foam dressing applied within 24 hours of hospital admission compared with standard preventive pressure injury (PI) care in reducing sacral PI occurrence in older patients with hip fractures.

DESIGN

Open-label, parallel-group, 2-arm, superiority trial.

SUBJECTS AND SETTING

The sample comprised older patients aged 69 to 97 years admitted to a 1500-bed university hospital in Bologna, Italy, for hip fracture surgery.

METHODS

Patients were randomly allocated to an intervention or control group. Both groups received standard evidence-based PI preventive care in accordance with National Pressure Ulcer Advisory Panel guidelines. In addition, patients in the intervention group received a single 12.9 × 12.9-cm multilayered polyurethane foam dressing shaped for the sacrum area applied within 24 hours of hospital admission. Bivariate analysis on primary and secondary outcomes and baseline characteristics was performed to compare group differences, and a survival analysis was used to determine the difference in PI incidence rates per group.

RESULTS

Sixty-eight patients completed the trial; 34 patients were allocated to the intervention group and 34 patients to the control group. A trend toward significance was observed for sacral PI occurrence in the intervention group (intervention: 20.6%; control: 2.9%; P = .054). The foam dressing allowed significantly longer time (days) to PI occurrence (intervention: 5.9 ± 1.60; control: 2.7 ± 0.96; P = .003).

CONCLUSIONS

These findings suggest that multilayered polyurethane foam dressings are not superior to the standard preventive PI care alone and should be used with caution, especially when multiple dressing changes may occur. Further exploration of the role of multilayered polyurethane foam dressings in preventing PI development is warranted.

International consensus on pressure injury preventative interventions by risk level for critically ill patients: A modified Delphi study

The aim of this modified Delphi study was to determine a minimum pressure injury preventative intervention set for implementation relative to critically ill patients' risk level. Preventative interventions were identified via systematic review, risk levels categorised by an intensive-care-specific risk-assessment-scale (COMHON Index), and panel members (n = 67) identified through an international critical care nursing body. Round 1: panel members were asked to rate implementation of 12 interventions according to risk level (low, moderate, high). Round 2: interventions were rated for use at the risk level which received greatest round 1 support. Round 3: interventions not yet achieving consensus were again rated, and discarded where consensus was not reached. Consensus indicated all patients should receive: risk assessment within 2-hours of admission; 8-hourly risk reassessment; and use of disposable incontinence pads. Additionally, moderate- and high-risk patients should receive: a reactive mattress support surface and a heel off-loading device. High-risk patients should also receive: nutritional supplements if eating orally; preventative dressings (sacral, heel, trochanteric); an active mattress support surface; and a pressure-redistributing cushion for sitting. Repositioning is required at least 4-hourly for low-risk, and 2-hourly for moderate- and high-risk patients. Rigorous application of the intervention set has the potential to decrease pressure injuries in intensive care.

A multilayer polyurethane foam dressing for pressure ulcer prevention in older hip fracture patients: an economic evaluation

OBJECTIVE

Hospital-acquired pressure ulcers (PU) have a substantial negative impact on patients and continue to impose a cost burden on hospital providers. Since the incidence of fragility fracture is growing, driven by the increase in the older population, it is expected that the overall incidence of associated complications will also increase accordingly. The aim of this economic evaluation was to determine whether the use of a multilayer, silicone-adhesive polyurethane foam dressing (ALLEVYN LIFE, Smith & Nephew, UK) alongside standard prevention (SP) for the prevention of PUs in older patients with hip fractures is a cost-effective strategy, compared with SP alone.

METHOD

A decision-analytic model was constructed to determine the incremental cost and effectiveness of the foam dressing strategy from the perspectives of the Italian and US hospital systems. We also performed one-way and probabilistic sensitivity analyses.

RESULTS

The foam dressing intervention was found to be cost saving and more effective than SP in both Italy and the US. Switching to foam dressing and standard prevention would result in an expected cost saving of €733 per patient in Italy and $840 per patient in the US, reducing the per-patient cost of treating PUs by 37-69% and 36-68%, respectively. The one-way and probabilistic sensitivity analyses demonstrate that the strategy remains dominant over a range of values of the input variables.

CONCLUSION

The foam dressing intervention is likely to be a cost-effective strategy compared with standard prevention alone.

Time-to-treatment is a risk factor for the development of pressure ulcers in elderly patients with fractures of the pelvis and acetabulum

INTRODUCTION

Fractures of the pelvis and acetabulum are associated with pain and immobilization and, hence, pose the risk of developing a pressure ulcer - especially in elderly patients. In the literature, information on risk factors for the occurrence of pressure ulcers related to geriatric pelvic or acetabulum fractures is missing.

METHODS

Consecutive in-hospital patients aged 55 years or older treated for closed pelvis and/or acetabulum fractures between 2013 and 2017 were retrospectively identified from an institutional prospective database. Epidemiologic characteristics and patient specifics with special focus on the time from admission to treatment, duration of hospitalization and comorbidities were retrospectively assessed by chart review.

RESULTS

During the evaluated interval, 407 patients with isolated fractures of the pelvis or acetabulum (mean age 78 years, range 55 to 101 years, 69,3% female) were treated. A new pressure ulcer that developed during the hospitalization was observed in 46/407 patients (11.3%). This included pressure ulcers of stage 1 in 18/46 cases (39%), stage 2 in 24/46 cases (52%), and stage 3 in 4/46 cases (9%). No stage 4 ulcers were seen in this cohort. The mean duration of hospitalization was longer in patients with a pressure ulcer (25 days, SD 17) than in patients with no ulcers (12 days, SD 9; p < .001). Patients who developed a pressure ulcer, had waited significantly longer for treatment of their pelvis/acetabulum fracture when compared to patients without an ulcer (5 days, SD 5 vs. 3 days SD 4, p = =.001). A logistic regression analysis confirmed "time to treatment" as an independent risk factor for the occurrence of a pressure ulcer during hospitalization. In an analysis adjusted for the confounders age, male gender, diabetes and malignancy, the odds ratio to develop a pressure ulcer remained 1.10 (CI 1.03 to 1.19; c-value = 0.774, p = .008) for each day of waiting treatment.

CONCLUSION

"Time to treatment" is an independent risk factor for the occurrence of a pressure ulcer during hospitalization after a pelvis/acetabulum fracture in elderly patients. Each day of waiting treatment increases the risk of developing a pressure ulcer by 10%.

Effectiveness on hospital-acquired pressure ulcers prevention: a systematic review

The effective approach on pressure ulcer (PU) prevention regarding patient safety in the hospital context was evaluated. Studies were identified from searches in EBSCO host, PubMed, and WebofScience databases from 2009 up to December 2018. Studies were selected if they were published in English, French, Portuguese, or Spanish; incidence of PUs was the primary outcome; participants were adults (≥18 years) admitted in hospital wards and/or units. The review included 26 studies. Studies related to prophylactic dressings applied in the sacrum, trochanters, and/or heels, education for health care professionals, and preventive skin care and system reminders on-screen inpatient care plan were effective in decreasing PUs. Most of the studies related to multiple intervention programmes were effective in decreasing PU occurrence. Single interventions, namely support surfaces and repositioning, were not always effective in preventing PUs. Repositioning only was effective when supported by technological pressure-mapping feedback or by a patient positioning system. Risk-assessment tools are not effective in preventing PUs. PUs in the hospital context are still a worldwide issue related to patient safety. Multiple intervention programmes were more effective in decreasing PU occurrence than single interventions in isolation. Single interventions (prophylactic dressings, support surfaces, repositioning, preventive skin care, system reminders, and education for health care professionals) were effective in decreasing PUs, which was always in compliance with other preventive measures. These results provide an overview of effective approaches that should be considered when establishing evidence-based guidelines to hospital health care professionals and administrators for clinical practice effective in preventing PUs.

Dressings and topical agents for preventing pressure ulcers

BACKGROUND

Pressure ulcers, localised injuries to the skin or underlying tissue, or both, occur when people cannot reposition themselves to relieve pressure on bony prominences. These wounds are difficult to heal, painful, expensive to manage and have a negative impact on quality of life. Prevention strategies include nutritional support and pressure redistribution. Dressing and topical agents aimed at prevention are also widely used, however, it remains unclear which, if any, are most effective. This is the first update of this review, which was originally published in 2013.

OBJECTIVES

To evaluate the effects of dressings and topical agents on pressure ulcer prevention, in people of any age, without existing pressure ulcers, but considered to be at risk of developing one, in any healthcare setting.

SEARCH METHODS

In March 2017 we searched the Cochrane Wounds Group Specialised Register, CENTRAL, MEDLINE, MEDLINE (In-Process & Other Non-Indexed Citations), Embase, and EBSCO CINAHL Plus. We searched clinical trials registries for ongoing trials, and bibliographies of relevant publications to identify further eligible trials. There was no restriction on language, date of trial or setting. In May 2018 we updated this search; as a result several trials are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that enrolled people at risk of pressure ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias and extracted data.

MAIN RESULTS

The original search identified nine trials; the updated searches identified a further nine trials meeting our inclusion criteria. Of the 18 trials (3629 participants), nine involved dressings; eight involved topical agents; and one included dressings and topical agents. All trials reported the primary outcome of pressure ulcer incidence.Topical agentsThere were five trials comparing fatty acid interventions to different treatments. Two trials compared fatty acid to olive oil. Pooled evidence shows that there is no clear difference in pressure ulcer incidence between groups, fatty acid versus olive oil (2 trials, n=1060; RR 1.28, 95% CI 0.76 to 2.17; low-certainty evidence, downgraded for very serious imprecision; or fatty acid versus standard care (2 trials, n=187; RR 0.70, 95% CI 0.41 to 1.18; low-certainty evidence, downgraded for serious risk of bias and serious imprecision). Trials reported that pressure ulcer incidence was lower with fatty acid-containing-treatment compared with a control compound of trisostearin and perfume (1 trial, n=331; RR 0.42, 95% CI 0.22 to 0.80; low-certainty evidence, downgraded for serious risk of bias and serious imprecision). Pooled evidence shows that there is no clear difference in incidence of adverse events between fatty acids and olive oil (1 trial, n=831; RR 2.22 95% CI 0.20 to 24.37; low-certainty evidence, downgraded for very serious imprecision).Four trials compared further different topical agents with placebo. Dimethyl sulfoxide (DMSO) cream may increase the risk of pressure ulcer incidence compared with placebo (1 trial, n=61; RR 1.99, 95% CI 1.10 to 3.57; low-certainty evidence; downgraded for serious risk of bias and serious imprecision). The other three trials reported no clear difference in pressure ulcer incidence between active topical agents and control/placebo; active lotion (1 trial, n=167; RR 0.73, 95% CI 0.45 to 1.19), Conotrane (1 trial, n=258; RR 0.74, 95% CI 0.52 to 1.07), Prevasore (1 trial, n=120; RR 0.33, 95% CI 0.04 to 3.11) (very low-certainty evidence, downgraded for very serious risk of bias and very serious imprecision). There was limited evidence from one trial to determine whether the application of a topical agent may delay or prevent the development of a pressure ulcer (DermalexTM 9.8 days vs placebo 8.7 days). Further, two out of 76 reactions occurred in the DermalexTM group compared with none out of 91 in the placebo group (RR 6.14, 95% CI 0.29 to 129.89; very low-certainty evidence; downgraded for very serious risk of bias and very serious imprecision).DressingsSix trials (n = 1247) compared a silicone dressing with no dressing. Silicone dressings may reduce pressure ulcer incidence (any stage) (RR 0.25, 95% CI 0.16 to 0.41; low-certainty evidence; downgraded for very serious risk of bias). In the one trial (n=77) we rated as being at low risk of bias, there was no clear difference in pressure ulcer incidence between silicone dressing and placebo-treated groups (RR 1.95, 95% CI 0.18 to 20.61; low-certainty evidence, downgraded for very serious imprecision).One trial (n=74) reported no clear difference in pressure ulcer incidence when a thin polyurethane dressing was compared with no dressing (RR 1.31, 95% CI 0.83 to 2.07). In the same trial pressure ulcer incidence was reported to be higher in an adhesive foam dressing compared with no dressing (RR 1.65, 95% CI 1.10 to 2.48). We rated evidence from this trial as very low certainty (downgraded for very serious risk of bias and serious imprecision).Four trials compared other dressings with different controls. Trials reported that there was no clear difference in pressure ulcer incidence between the following comparisons: polyurethane film and hydrocolloid dressing (n=160, RR 0.58, 95% CI 0.24 to 1.41); Kang' huier versus routine care n=100; RR 0.42, 95% CI 0.08 to 2.05); 'pressure ulcer preventive dressing' (PPD) versus no dressing (n=74; RR 0.18, 95% CI 0.04 to 0.76) We rated the evidence as very low certainty (downgraded for very serious risk of bias and serious or very serious imprecision).

AUTHORS' CONCLUSIONS

Most of the trials exploring the impact of topical applications on pressure ulcer incidence showed no clear benefit or harm. Use of fatty acid versus a control compound (a cream that does not include fatty acid) may reduce the incidence of pressure ulcers. Silicone dressings may reduce pressure ulcer incidence (any stage). However the low level of evidence certainty means that additional research is required to confirm these results.

Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial

Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi‐layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14‐0.61) with NNT of 9 (95% CI 6‐21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down.