Effectiveness of prophylactic sacral protective dressings to prevent pressure injury: A systematic review and meta-analysis

Incidence of Pressure Injury Among Older Adults Transitioning from Long-term Care to the ED

OBJECTIVE

To identify sociodemographic, health condition, and organizational/process factors associated with pressure injury (PI) incidence during older adults' emergency transitions from long-term care (LTC) to the ED.

METHODS

Emergency transitions were tracked for older adults within included LTC facilities to participating EDs in two urban centers located in provinces in Canada. Binary logistic regression was used to examine the influence of sociodemographic, service use, and client health and function factors on the incidence of PIs during transitions from LTC facilities to EDs.

RESULTS

Having a mobility issue (odds ratio [OR], 4.318; 95% CI, 1.344-13.870), transitioning from a publicly owned versus a nonprofit volunteer LTC facility (OR, 4.886; 95% CI, 1.157-20.634), and time from ED arrival to return to LTC being 7 to 9 days (OR, 41.327; 95% CI, 2.691-634.574) or greater than 9 days (OR, 77.639; 95% CI, 5.727-1,052.485) significantly increased the odds of experiencing a new skin injury upon return to LTC. A higher number of reported reasons for emergency transition (up to 4) significantly decreased the odds of a new PI upon return to LTC (OR, 0.315; 95% CI, 0.113-0.880).

CONCLUSIONS

The study findings can be used to identify LTC residents at increased risk for developing new skin injuries during an emergency transition, namely, those with mobility impairment, those requiring inpatient care for 6 or more days, and those transitioning from publicly owned LTC facilities. Evaluating the uptake and effectiveness of single-pronged and multipronged interventions such as visual cues for patient turning through online monitoring, consistent risk assessments, and improved nutrition in all care settings are vital next steps in preventing skin injuries in this population.

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.

Pressure injury prevention practice in Australian intensive care units: A national cross-sectional survey

INTRODUCTION

Pressure injury (PI) is an ongoing problem for patients in intensive care units (ICUs). The aim of this study was to explore the nature and extent of PI prevention practices in Australian adult ICUs.

MATERIALS AND METHODS

An Australian multicentre, cross-sectional study was conducted via telephone interview using a structured survey instrument comprising six categories: workplace demographics, patient assessment, PI prevention strategies, medical devices, skin hygiene, and other health service strategies. Publicly funded adult ICUs, accredited with the College of Intensive Care Medicine, were surveyed. Data were analysed using descriptive statistics and chi-square tests for independence to explore associations according to geographical location.

RESULTS

Of the 75 eligible ICUs, 70 responded (93% response rate). PI was considered problematic in two-thirds (68%) of all ICUs. Common PI prevention strategies included risk assessment and visual skin assessment conducted within at least 6 h of admission (70% and 73%, respectively), a structured repositioning regimen (90%), use of barrier products to protect the skin (94%), sacrum or heel prophylactic multilayered silicone foam dressings (88%), regular PI chart audits (96%), and PI quality improvement projects (90%). PI prevention rounding and safety huddles were used in 37% of ICUs, and 31% undertook PI research. Although most ICUs were supported by a facility-wide skin integrity service, it was more common in metropolitan ICUs than in rural and regional ICUs (p < 0.001). Conversely, there was greater involvement of occupational therapists in PI prevention in rural or regional ICUs than in metropolitan ICUs (p = 0.026).

DISCUSSION AND CONCLUSION

This is the first study to provide a comprehensive description of PI prevention practices in Australian ICUs. Findings demonstrate that PI prevention practices, although nuanced in some areas to geographical location, are used in multiple and varied ways across ICUs.

Prophylactic use of silicone dressing to minimize pressure injuries: Systematic review and meta-analysis

OBJECTIVE

Preventing hospital-acquired pressure injuries (PI) in critically ill patients remains a significant clinical challenge because of its associated high risk for comorbid conditions. We assessed the preventive effectiveness of silicone dressings among patients admitted in intensive care units and non-intensive care units settings.

METHODS

A literature search was conducted across 3 electronic databases (MEDLINE, EMBASE, Cochrane Central) from inception through December 2021. Studies assessing the effectiveness of silicone dressing on the incidence of PI on the sacral area were included. Evaluations were reported as risk ratios (RRs) with 95% confidence interval, and analysis was performed using a random-effects model.

RESULTS

Of the 1056 articles retrieved from the initial search, 11 studies were included in the final analysis. Silicone dressings significantly reduced the incidence of PI compared to usual care (RR: 0.30, 95% CI: 0.19-0.45, P<0.01). We found no significant difference between results of studies conducted in intensive care settings (RR=0.25, 95% CI: 0.15-0.43, P<0.01) and non-intensive care settings (RR=0.38, 95% CI: 0.17-0.83, P=0.01) (P-interaction: 0.39). Silicone dressings reduced the risk of developing PI among patients using five-layer foam Border dressing (Mepilex® Sacrum) (RR: 0.31, 95% CI: 0.20-0.48, P<0.01), and dressing Allevyn Gentle Border® (RR: 0.10, 95% CI: 0.01-0.73, P=0.02) with no significant difference upon subgroup analysis (P-interaction: 0.27).

CONCLUSION

The present meta-analysis suggests that silicone dressings consistently reduce the incidence of PI in intensive as well as in non-intensive care settings, regardless of the type of dressing used.

Prevention and management of hospital-acquired pressure injury among patients with lung disease in a hospital: a best practice implementation project

OBJECTIVES

The aim of this project was to promote evidence-based practice in the prevention and management of pressure injury in lung disease patients.

INTRODUCTION

Pressure injury is a crucial quality indicator for hospital care of patients. The pressure injury incidence threshold in the chest wards has been exceeding that of the general ward (0.128%), which may extend patients' hospital stay.

METHODS

Clinical audits were performed using the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. Twelve audit criteria representing best practice recommendations for preventing and managing pressure injury among lung disease patients were used. A baseline audit was performed to measure the degree of consistency between existing practice and best practice. This project used the GRiP analysis and multiple strategies to develop care protocols for pressure injury prevention and management. A follow-up audit was conducted to measure changes in clinical practice and pressure injury incidence.

RESULTS

Postimplementation audit compliance rates improved for the following criteria: skin assessment for identifying pressure injury indications (from 31 to 81%), identification of pressure injury risk score/category (from 19 to 88%), employment of nutritional assessment tools (from 8 to 93%), and provision of information regarding oral nutritional supplements (from 23 to 84%). Furthermore, patients learning the pressure injury care protocols (from 48 to 93%), the receipt of additional skin protection measures, and repositioning of vulnerable areas to relieve pressure increased to 100 and 93%, respectively. After project implementation, the monthly pressure injury incidence decreased markedly from 0.075 to 0.021%.

CONCLUSION

The success factors of this project are attributable to leadership, open communication, multiple learning-by-doing strategies, regular audits, and the promotion of patient and family engagement.

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.

Alternatives and preferences for materials in use for pressure ulcer prevention: An experiment-reinforced literature review

Alleviation of localised, sustained tissue loads and microclimate management are the most critical performance criteria for materials in use for pressure ulcer prevention, such as in prophylactic dressings, padding or cushioning. These material performance criteria can be evaluated by calculating the extents of matching between the material stiffness (elastic modulus) and the thermal conductivity of the protective dressing, padding or cushioning with the corresponding properties of native skin, separately or in combination. Based on these bioengineering performance criteria, hydrocolloids, which are commonly used for prophylaxis of medical device-related pressure ulcers, exhibit poor stiffness matching with skin. In addition, there is remarkable variability in the modulus and thermal conductivity matching levels of different material types used for pressure ulcer prevention, however, it appears that among the materials tested, hydrogels provide the optimal matching with skin, followed by gels and silicone foams. The stiffness matching for hydrocolloids appears to be inferior even to that of gauze. This article provides quantitative performance criteria and metrics for these evaluations, and grades commonly used material types to biomechanically guide clinicians and industry with regards to the selection of dressings for pressure ulcer prevention, both due to bodyweight forces and as a result of applied medical devices.

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.

Management of Chronic Wounds

Chronic wounds originate from venous hypertension, arterial insufficiency, or pressure-induced ischemia. Determination of the type and associated causes and contributory conditions is essential for the diagnosis and management of these common conditions.

The prevention of pressure injuries in the positioning and mobilization of patients in the ICU: a good clinical practice document by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BACKGROUND

The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU).

METHODS

A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient.

RESULTS

The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients' positions, including the prone position; five suggested specific screening tools and patients' factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings.

CONCLUSIONS

The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.

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.

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).

Pressure injury prevalence and risk factors in Chinese adult intensive care units: A multi-centre prospective point prevalence study

Despite increasing preventive efforts, pressure injury still occurs in intensive care patients. This study was aimed to describe pressure injury prevalence, risk factors, and prevention practices in adult intensive care patients. This was a multi-centre, one-day, prospective point prevalence study in which a total of 198 intensive care units from 21 provinces in China participated. Overall and ICU-acquired prevalence in intensive care patients were 12.26% and 4.31%, respectively. Consistent with earlier reports, almost half of the ICU-acquired pressure injuries were at stage I, one-fourth were at stage 2, and the most common body sites for pressure injuries were sacral and heel region. Risk factors identified were consistent with prior studies. Repositioning was the most commonly used pressure injury prevention strategy, followed by alternating pressure mattresses/overlays, floating heels, and air-filled mattresses/overlays. These reflect a good level of adherence to recommended international pressure injury prevention clinical practice guidelines. The results provide a baseline reference for overall and ICU-acquired prevalence among adult intensive care patients in China. Future research on what contributed to the lower pressure injury incidence in China needs to be conducted to inform healthcare organisations on their future preventive strategies for pressure injury prevention.

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BACKGROUND

Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.

OBJECTIVES

The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.

METHODS

A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.

RESULTS

Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126).

CONCLUSIONS

We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

Pressure ulcer prevention dressing design and biomechanical efficacy

The objective of this educational article is to explain in non-technical terms how the engineering considerations in the design of prophylactic dressings for pressure ulcer (PU, also known as pressure injury) prevention eventually determine the associated clinical and cost-benefit outcomes. The article specifically describes a bioengineering algorithm for quantitative evaluation of the biomechanical efficacy of different prophylactic dressing designs, which is exemplified for two fundamentally different dressing technologies, one based on superabsorbent cellulose core versus the conventional silicone-foam dressing design. A set of three biomechanical indices is described and employed for the above comparative evaluation, namely, the protective efficacy index, the protective endurance and the prophylactic trade-off design parameter. It is demonstrated that the dressing with the superabsorbent cellulose core is at least as good as silicone-foams but, importantly, provides a good balance between its protective performance in its ‘new’ condition, as opposed to its ‘used’ condition, i.e., after being exposed to moisture. Most notably, we show that preventative dressings are never equal in their performances; the underlying structure and the dressing ingredients together determine the extent of the delivered tissue protection and its durability.

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.

Skin and Mucosal Damage in Patients Diagnosed With COVID-19: A Case Report

Patients admitted to the intensive care unit (ICU) are at a high risk for developing pressure injuries. A patient requiring multiorgan support is at a higher risk for pressure injuries related to immobility, sedation, vasopressors, and hypoxia. To mitigate pressure injuries, our hospital utilizes a bundle approach to prevent skin injury. However, despite efforts to prevent pressure injuries, we found our patients in the ICU with the diagnosis of COVID-19 went on to develop significant pressure and mucosal injuries. This is a case report of 4 patients diagnosed with COVID-19 who developed significant skin and mucosal injuries during their ICU admissions in the month of March 2020. We found that patients developed skin conditions that were initially thought to be deep-tissue injuries (DTIs) early in the admission. The DTIs progressed over the course of the admission in the ICU and evolved to thick adherent eschar that appeared to be unstageable pressure injuries, which extended beyond the soft tissue directly over the bony prominence. We also found that skin damage to the mucosa of the nares, tongue, lips, and urethra presented first as inflammation and then progressed to thick eschar. Despite maximum pressure relief with the use of a pressure-relieving turn and position system, bordered foam dressings, fluidized positioners, specialty beds, and leadership support for twice-a-week skin checks, our patients diagnosed with COVID-19 developed extensive skin damage across the fleshy portion of the buttocks and on the mucosa of the nares, tongue, lips, and urethra during minimal exposure to pressure. Although the initial presentation of the skin damage appeared to be related to pressure, the extent of the skin damage suggests a vascular inflammatory process beyond skin damage related to pressure.

The biomechanical efficacy of a dressing with a soft cellulose fluff core in prophylactic use

In this work, we developed an experimental-computational analysis framework which facilitated objective, quantitative, standardised, methodological, and systematic comparisons between the biomechanical efficacies of two fundamentally different dressing technologies for pressure ulcer prevention: A dressing technology based on cellulose fibres used as the core matrix was evaluated vs the conventional silicone-foam dressing design concept, which was represented by multiple products which belong in this category. Using an anatomically-realistic computer (finite element) model of a supine female patient to whom the different sacral dressings have been applied virtually, we quantitatively evaluated the efficacy of the different dressings by means of a set of 3 biomechanical indices: The protective efficacy index, the protective endurance, and the prophylactic trade-off design parameter. Prior rigorous experimental measurements of the physical and mechanical behaviours and properties of each tested dressing, including tensile, compressive, and friction properties, have been conducted and used as inputs for the computer modelling. Each dressing was evaluated for its tissue protection performances at a new (from the package) state, as well as after exposure to moisture conditions simulating wet bedsheets. Our results demonstrated that the dressing with the fluff core is at least as-good as silicone-foams but importantly, provides the best balance between protective performances at its "new" condition and the performance after being exposed to moisture. We conclude that preventative dressings are not equal in their prophylactic performances, but rather, the base technology, the ingredients, and their arrangement in the dressing structure shape the quality of the delivered tissue protection.

Development and validation of an ICU-specific pressure injury risk assessment scale

BACKGROUND

Critically ill patients are at high risk for pressure injury (PI) due to critical illness combined with multiple interventions and therapies. It is hence important to gain more knowledge about the risk factors associated with pressure injury development and methods for decreasing its prevalence.

AIMS

To develop and validate a clinical useful ICU-specific PI risk assessment scale based on the RAPS.

METHOD

The study was designed as a prospective instrument development and validation study. The Risk Assessment Pressure Ulcer Scale (RAPS), which in Sweden is a commonly used PI risk assessment scale, was used as a starting point. Development was then performed in different steps; adaption of items and response options to ICU care, discussion with ICU staff members to enhance clinical relevance and usability, test of interrater reliability, revision of instrument, a new test with 300 patients followed by statistical evaluation.

RESULTS

The final version of the RAPS-ICU consists of six items: failure of vital organs, mobility, moisture, sensory perception, level of consciousness and special treatment in the form of mechanical ventilation, continuous dialysis and/or inotropic drugs. A total score was reached by summing all responses. Each of the items was found to be significant associated with PI development as well as the total score (p < 0.001). The total score also showed a high interrater reliability (ICC = 0.96), good sensitivity and acceptable specificity with AUC = 0.71 and ICU staff perceived the RAPS-ICU as relevant and easy to use in clinical practice.

CONCLUSION

The RAPS-ICU is a valid and clinically useful tool to identify patients at risk to develop pressure injury at ICU.